«rirev^iffiraKV»^^ 


^HANDBOOK 


INCLUDING  SECTIONS  ON  THE  X-RAY,  HIGH- 
FREQUENCY  CURRENT  AND  THE  MINOR 
SURGERY  OF  THE  SKIN 

FOR  THE  USE  OF  GENERAL  PRACTITIONERS 


.\y   /          BY 
v 

W.  A.  HARDAWAY,  M.D.,  LL.D. 

PROFESSOR  OF    DISEASES  OF  THK    SKIN    AND    SYPHILIS  IN   WASHINGTON    UNIVERSITY 

ST.  LOUIS 

AND 

JOSEPH  GRINDON,  Pn.B.,  M.D. 

PROFESSOR    OF    CLINICAL    DERMATOLOGY    AND    SYPHILIS      IN     WASHINGTON 
UNIVERSITY,  ST.   LOUIS 


LEA  BROTHERS  &   CO. 
PHILADELPHIA     AND    NEW     YORK 

1907 


vu 
14 
1907 


Entered  according  to  Act  of  Congress,  in  the  year  1907,  by 

LEA  BROTHERS  &  CO. 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE. 


THIS  book  is  based  upon  the  descriptive  and  therapeutic 
sections  of  Hardaway's  Manual  of  Skin  Diseases,  which 
parts,  however,  have  been  considerably  revised  and  ex- 
tended. It  is,  therefore,  proper  to  state  that,  with  some 
few  exceptions,  Dr.  Hardaway  has  written  the  descrip- 
tions of  the  various  diseases  and  all  that  relates  to  their 
general  and  medicinal  treatment,  while  Dr.  Grindon  has 
prepared  the  special  sections  on  radiotherapy,  the  high- 
frequency  current,  galvanism,  faradism,  minor  surgical 
procedures,  and,  in  fact,  what  may  be  termed  the  physical 
and  mechanical  treatment.  Of  course,  it  will  be  understood 
besides  that  both  authors  have  jointly  supervised  the  work 
as  a  whole. 

Dr.  Isadore  Dyer,  of  New  Orleans,  has  been  good  enough, 
in  the  article  on  Leprosy,  to  give  the  authors  the  advantage 
of  his  exceptional  experience  in  the  treatment  of  that  dis- 
ease, and  Professor  J.  M.  Good,  of  the  St.  Louis  School 
of  Pharmacy,  has  contributed  some  useful  notes  on  the 
preparation  of  ointments. 

A  few  words  on  the  general  plan  and  scope  of  this  work 
may  be  added.  In  many  instances,  to  make  the  principles 
of  treatment  clear,  we  have  gone  very  fully  into  the  symp- 
tomatology and  etiology;  on  the  other  hand,  where  this 
necessity  did  not  seem  apparent,  these  features  have  been 
dealt  with  in  the  briefest  wav.  A  certain  amount  of  atten- 


iv  PREFACE 

tion  has  also  been  given  to  differential  diagnosis.  We  have 
for  the  most  part  omitted  all  mention  of  rare  and  unim- 
portant diseases. 

This  book  has  not  been  written  for  the  specialist,  but  for 
the  general  physician,  who  is  necessarily  obliged  to  treat 
skin  diseases,  and  who  demands  practical  advice.  We  have, 
therefore,  tried  to  keep  this  fact  before  us,  and  endeavored 
to  place  at  the  disposal  of  the  physician  means  and  methods 
that  are  readily  accessible,  and  have  rarely  mentioned 
drugs  and  appliances  that  are  beyond  the  reach  or  skill 
of  the  ordinary  pharmacist.  At  the  risk  of  appearing 
unfamiliar  with  much  of  the  passing  literature  of  the  day, 
we  have  avoided  mentioning  the  many  novel  therapeutic 
ventures  that  are  often  forgotten  the  week  after  their 
publication. 

At  the  end  of  many  of  the  sections  are  appended  carefully 
selected  formula*,  in  addition  to  those  in  the  text  proper — a 
feature  that  we  trust  will  prove  useful. 

In  Part  II  there  will  be  found  a  fairly  full  account  of 
the  newer  methods  of  treatment,  such  as  the  ar-ray,  the 
high-frequency  current,  the  opsonic  method,  electrolysis, 
etc.,  together  with  a  brief  consideration  of  the  minor 
surgery  of  cutaneous  disorder^. 

It  is  needless  to  say  that,  while  the  text  reflects  our  own 
personal  experiences,  we  have  drawn  fully  upon  the  cur- 
rent dermatological  journals  and  year  books  and  the  many 
valuable  treatises  on  cutaneous  medicine. 

It  remains  to  express  our  sincere  thanks  to  Dr.  ('.  I). 
Scott  for  much  valuable  aid  in  the  preparation  of  the 
manuscript  and  to  Dr.  H.  II .  Davis  for  similar  assistance. 

W.  A.  H. 

j.  <;. 

-!.  LOT  I-.   1!M)7 


CONTENTS. 


PART    I. 
TREATMENT  OF  DISEASES  OF  THE  SKIN. 

INFLAMMATIONS. 

The  Erythemas:  E.  simplex — E.  idiopathicum — E.  intertrigo 

— E.  symptomaticum — E.  scarlatiniforme — E.  pernio  .  .  17 
The  Exudative  Erythemas:  E.  multiforme — Herpes  iris — E. 

nodosum — E.  elevatum  diutinum 24 

Erysipelas 29 

Erysipeloid 33 

Pellagra  33 

Furuncle 35 

Carbuncle 40 

Malignant  pustule 43 

Equinia 44 

Impetigo  contagiosa 45 

Ecthyma 48 

Pompholyx 50 

Herpes  simplex:  H.  facialis — H.  progenitalis 52 

Herpes  zoster 55 

Repeating  neuralgic  herpes 60 

Pemphigus:  P.  acutus — P.  vulgaris — P.  vegetans — P.  foli- 

aceus 60 

Impetigo  herpetiformis 65 

Dermatitis  herpetiformis 66 

Hydroa  vacciniforme,  seu  sestivale 70 

Epidermolysis 71 

Eczema,  General  description:  E.  erythematosum — E.  papu- 

losum — E.    vesiculosum — E.   pustulosum — E.    rubrum — E. 

squamosum  —  other     forms — Etiology  —  Treatment :    Diet, 


vi  CONTENTS 

Internal  treatment — General  principles  of  local  treatment: 
Lotions — Powders  — Liniments  — Ointments  — Pastes — Gly- 
cerine jelly — Plasters — Paints — Baths — Mechanical  treat- 
ments— Regional  forms-  E.  of  scalp,  of  face,  of  lips,  of 
lids,  of  beard,  of  breast  and  nipples,  of  the  umbilicus,  of 
the  flexor  surfaces  of  joints — E.  intertrigo — E.  of  anus  and 
perineum — E.  of  the  genitals — E.  of  the  hands  and  feet — E. 
of  the  nails — E.  of  the  legs — Universal  E. — E.  infantile — 

Treatment  of  eczema  by  z-rays,  etc. — Prognosis        ...  71 

Ulcus  varicosus 126 

Eczema  seborrhoicum 131 

Dermatitis  repens 135 

Prurigo 136 

Psoriasis 137 

Pityriasis  maculata  et  c  rcinata 150 

Dermatitis  exfoliativa — Acute  exfoliative  dermatitis — Pity- 
riasis rubra — Derm,  exfol.  infantum — Derm,  exfol.  epidemica  152 

Psoriasiform  dermatoses 156 

Urticaria:  Acute  urticaria — Chronic  urticaria 157 

Urticaria  pigmentosa 163 

Edema:  symptomatic  E. — Acute  circumscribed  E 164 

Lichen  planus 165 

Lichen  pilaris  (Crocker) 171 

Pityriasis  rubra  pilaris 172 

Dermatitis  gangra>nosa:  Multiple  gangrene — Diabetic  gan- 
grene— Symmetrical  gangrene  (Raynaud's  disease)  Der- 
matitis G.  infantum 175 

Dermatitis  medicamentosa 178 

Dermatitis  factitia 180 

Dermatitis  traumatica         181 

Dermatitis  venenata 181 

Dermatitis  calorica 184 

X-ray  dermatitis 18(» 

HEMORRHAGES. 
Purpura:  P.  simplex — P.  ha-morrhagica — P.  rheumntion  .      .      188 

HYPERTROPHIES. 

Lentigo 192 

Chloasma 193 

Tattoo  marks  and  powder  stains 196 


CONTENTS  vii 

Keratosis  pilaris 198 

Keratosis  palmaris  et  plaiitaris 199 

Keratosis  senilis 201 

Kerato-angioma 203 

Porokeratosis 203 

Callositas 204 

Clavus 206 

Cornu  cutaneum 207 

Verruca:  V.    filiformis — V.    senilis — V.    plana    juvenilis — V. 

acuminata 207 

Narvus  pigmentosus 211 

Ichthyosis 212 

Sclerema  neonatorum 215 

(Edema  neonatorum 215 

Scleroderma 216 

Morphea 218 

Elephantiasis 220 

Mvxedema 223 

ATROPHIES. 

Leucoderma * 225 

Atrophia  cutis 227 

Perforating  ulcer 227 

Ainhum    .  228 


NEW  GROWTHS. 

Keloid 230 

Cicatrix 232 

Dermatitis  papillaris  capillitii         233 

Fibroma 233 

Myoma 235 

Neuroma 235 

Lipoma 236 

Xanthoma:  X.  planum — X.  tuherculatum — X.  diabeticorum.  236 
Angioma:  A.  simplex — A.  cavernosum — Nn-vus    Vascularis — 

Telangiectases 239 

Angioma  serpiginosum 246 

Lymphangioma  circumscriptum 246 

Xeroderma  pigmentosum 247 

Rhinoscleroma    .  249 


viii  CONTENTS 

Tuberculosis  of  the  skin :  Lupus  vulgaris — Treatment — Inter- 
nal :  Tuberculin—  Local :  Surgical — Medical — Phototherapy 
— The  x-ray — Tuberculosis  verrucosa — Scrot'uloderma — Pus- 
tular scrofulides 250 

Lichen  scrofulosus,  or  scrofulosorutn 271 

Erythema  induratum 272 

Blastomycosis 273 

Lupus  erythematosus 275 

The  Syphilodermata,  general  description :  S.  erythematosum — 
S.  papulosum — S.  pustulosum— S.  tuberculosum — S.  gumma- 
tosum — S.  bullosum — Treatment :  By  the  mouth — Inunction 
—  Hypodermic  injections  —  Fumigations  —  The  iodides  — 
Mixed  treatment — Hereditary  syphilis — Treatment  .      .      .     287 

Mycosis  fungoides 314 

Sarcoma  cutis:  Melanotic  S. — Non-pigmented  S. — Idiopathic 

multiple  pigmented  S.      .      . 317 

Leprosy :  Nodular  L. — Anesthetic  L. — Mixed  L. — Treatment .     320 

Colloid  degeneration 330 

Adenoma  sebaceum 331 

Multiple  benign  cystic  epithelioma 332 

Leucokeratosis  buccalis 332 

Keratosis  follicularis      .  * 335 

Keratosis  follicularis  contagiosa 336 

Molluscum  epitheliale 337 

Carcinoma  cutis:  Lenticular — Tuberose 338 

Epithelioma:  Superficial  E. — Deep  E. — Papillary  E. — Treat- 
ment— Surgical  —  Cauterant  —  Trypsin  treatment  —  Soap 
treatment  —  Cataphoresis  —  The  x-rays  —  Phototherapy  — 

Radium 339 

Paget's  disease  of  the  nipple 357 

Frambesia ....     359 

Furunculus  orientalis 360 

NEUROSES. 

Hyperesthesia 361 

Dermatalgia        361 

Anesthesia 362 

Pruritus:  P.  universalis — P.  localis — P.  hiemalis — P.  scroti — 

P.  ani — P.  vulvse        .      .      .  362 


CONTENTS  ix 

DISEASES  OF  THE  APPENDAGES  OF  THE  SKIN. 

DISEASES  OF  THE  SWEAT  GLANDS. 

Hyperidrosis — Bromidrosis — Chromidrosis — Anidrosis        .      .  376 

Hidradenitis  suppurativa 383 

Miliaria 384 

Sudainen         386 

Hidrocystoma 386 

Granulosis  rubra  nasi 387 

DISEASES  OF  THE  SEBACEOUS  GLANDS. 

Seborrhea 388 

Comedo 393 

Milium 395 

Atheroma 396 

Acne:  A.  simplex — A.  indurata — Treatment:  General — Local: 

Mechanical,  Medical,  A'-ray 397 

Acne  rosacea 413 

Acne  varioliformis 417 

AFFECTIONS  OF  THE  HAIR  FOLLICLES. 

Canities 419 

Hypertrichosis :  Electrolysis — The  x-ray 419 

Atrophia  pilorum  propria 428 

Trichorrhexis  nodosa 429 

Monilethrix 430 

Lepothrix 430 

Piedra 431 

Tinea  nodosa 431 

Folliculitis  capillitii  desquamativa 431 

Alopecia:  Congenital  A. — Senile  A. — Idiopathic  premature  A. 

-—Symptomatic  premature  A. — A.  pityrodes         ....  432 

Alopecia  areata         440 

Folliculitis  decalvans 446 

Sycosis 448 

DISKASKS  <>1    THE  NAILS. 

Onychuuxis ' 454 

Onychia .       .  456 

( >nychumyc(isis ...  1"^ 

Atropliia  unjiuium 458 


x  < '<>N  TENTS 

PARASITIC  DISEASES. 

VEGETABLE  PARASITIC  AFFECTIONS. 

Favus .      .  460 

Ringworm:  R.  of  scalp — R.  of  body — R.  of  beard  .      .  465 

Tinea  imbricata        480 

Tinea   versicolor 481 

Erythrasma •  483 

Pinta 484 

Mycetoma •  484 

Actinomycosis 485 

ANIMAL  PARASITIC  AFFECTIONS. 

Scabies 486 

Pediculosis:  P.  capillitii — P.  corporis — P.  pubis       ....  491 

Filaria  medinensis .  495 

Cysticercus  cellulose  cutis 496 

Creeping  eruption 496 

Myiasis 498 

Uncinarial  dermatitis  498 


PART  II. 
GENERAL  TREATMENT  AND  METHODS. 

Internal  treatment:  Diet — Arsenic — Antimony — Sulphur — 
Ichthyol  —  Quinine  —  Salicylic  acid — Phosphorus — Turpen- 
tine, tar  and  carbolic  acid — Calcium  chloride — Thyroid  gland 
— Suprarenal  gland- — Mercury — Iodides — Mineral  waters  .  501 

Local  applications:  Powders — Lotions  —  Ointments — salve- 
pencils —  Glycogelatins  —  Plasters  —  Caustics  —  Poultices — 
( )ils  and  liniments — Soaps — Paints  and  varnishes — Baths  .  505 

The  Opsonic  method — Theory — Determination  of  the  index 
—The  vaccines 520 

The  mixed  toxins  of  erysipelas  and  Bacillus  prodigiosus — 
Theorv— Method  .  526 


COX  TENTS  xi 

Galvanism 527 

Faradism 529 

Static  electricity 529 

High-frequency    currents :  Theory — Apparatus — Physiological 

properties— Applications 531 

Electrolysis:  Theory — Bipolar    method — Unipolar    method — 

Uses 535 

Cataphoresis :  Through  the  unbroken  skin — Through  an  ulcer- 
ated surface — Combined  with  electrolysis 536 

The  x-rays :  Physics — The  static  machine — The  coil — The  con- 
denser— Inductance — Spark-gaps — The  voltmeter  and  am- 
meter— Sources  of  energy — The  rheostat — The  interrupter — 
The  milliammeter — The  tube — The  tube  stand — Protection 
of  the  patient  and  operator — Choice  and  dosage  of  rays — 
Quality  of  the  rays — Quantity  of  rays  absorbed — Distance — 
Time — Quantity  of  rays  emitted  from  the  tube  in  a  given 
time — Dosage  concluded— Is  the  production  of  dermatitis 
necessary? — Effects  of  the  rays  on  tissues — Applications  to 

disease 538 

Radium:  Physics — Effects 574 

Phototherapy :      Physics — Negative    phototherapy — Positive 

phototherapy — Lamps — Technique — Uses 576 

Asepsis  and  antisepsis 580 

Anesthesia  (Local) — Freezing — Cocaine    and  its    congeners — • 

The  infiltration  methods 581 

Mechanical  methods :    The  curette — The  scarifier — The  punch — 
The   comedo  expressor — The   acne    lancet — The  epilating 

forceps 584 

The  Thermocautery — The  Paquelin  cautery — The     galvano- 

cautery 589 

Skin-grafting — The  Thiersch  method 590 

Hot  air 593 

Passive  hyperemia — Bier's  method 593 


ERRATA. 


Page  24,  line  28,  /or  tuberculous  read  tubercular. 

"     25,  "  20,  "  tuberculous     "  tubercular. 

"     64,  "  10,  "  croton  oil        "  carron  oil. 

''  313,  "  30,  "  doses  a  day    "  doses  3  times  a  day. 

"  388,  "  20,  "  seborrheicum "  seborrhoicum. 

"  447,  "  6,  "  Quinquad        "  Quinquaud. 

"  504,  "  15,  "  it  also  has       "  they  also  have. 

"  504,  "  17,  "  it  has  been      "  iodide  of  potassium  has  been 


PART  I. 
TREATMENT  OF  DISEASES  OF  THE  SKIN. 


INFLAMMATIONS. 

THE  ERYTHEMATA. 

Erythema  Simplex.  Description. — Erythema,  using  the 
word  in  a  clinical  sense,  may  be  defined  as  a  redness  of  the 
skin,  which  may  be  made  to  fade  upon  pressure.  It  appears 
in  the  shape  of  diffused  or  circumscribed,  variously  sized 
lesions,  generally  without  appreciable  elevation  above  the 
integument.  It  is  customary  to  divide  it  into  the  idiopathic 
and  symptomatic  varieties. 

Idiopathic  Erythema. — This  form  is  brought  about  by 
the  influence  of  external  irritation,  and  if  left  unchecked 
may  go  on  to  true  inflammation.  Among  the  exciting 
causes  may  be  mentioned  heat  and  cold,  traumatism,  and 
animal  and  vegetable  irritants. 

Treatment. — The  indications  for  treatment  are  suffi- 
ciently obvious,  namely,  to  remove,  when  practicable,  the 
exciting  cause  and  to  apply  some  simple  dusting  powder 
or  soothing  lotion. 

Erythema  Intertrigo. — This  form  of  erythema  is  always 
at  first  a  simple  hyperemia  of  the  skin,  which  occurs  in 
parts  of  the  body  exposed  to  friction  from  the  contact  of 
opposed  surfaces,  and,  in  children  especially,  it  is  often 
evoked  by  the  irritation  of  urinary  and  fecal  discharges. 
In  severe  cases  the  skin  is  hot  and  tender,  there  is  a  hyper- 
secretion  of  sweat,  the  epidermis  becomes  macerated,  and 
2 


18  INFLAMMATIONS 

the  parts  are  bathed  in  a  muciform  discharge,  which  fre- 
quently emits  a  highly  offensive  odor.  Under  circum- 
stances of  neglect,  the  surfaces  may  become  fissured,  raw, 
and  even  extensively  ulcerated. 

The  disease  is  usually  found  in  the  groins,  the  folds 
of  the  neck  in  fat  babies,  the  gluteal  furrows,  the  inner 
surfaces  of  the  thighs  and  flexures  of  the  joints.  Intertrigo 
in  infants  may  appear  quite  suddenly,  and,  under  proper 
management,  may  last  but  a  few  hours;  on  the  other  hand, 
if  neglected  or  improperly  treated,  it  may  persist  for  weeks. 
When  it  is  symptomatic  of  internal  disorders  of  a  grave 
character,  the  disease  persists  in  spite  of  the  best-directed 
efforts  at  cure.  It  is  most  frequently  encountered  in  hot 
weather,  although  in  infants  it  may  be  observed  at  all 
times  of  the  year.  Relapses  are  to  be  expected. 

Treatment. — In  the  management  of  intertrigo  it  is  also 
well  to  remember  that  the  affection  may  be  set  up  by  the 
dribbling  of  urine  in  elderly  men  with  prostatic  disease, 
by  the  irritating  influence  of  menstrual  and  vaginal  dis- 
charges, and  by  the  overflow  of  milk  from  distended 
breasts.  Fleshy  persons  of  a  gouty  habit  are  very  prone 
to  intertrigo,  and  it  is  necessary  in  these  cases  to  look 
carefully  after  the  diet  and  to  give  remedies  suitable  to  the 
constitutional  condition.  In  obstinate  attacks  in  adults 
the  urine  should  always  be  examined  for  sugar.  It  is 
generally  easy  to  prevent  the  occurrence  of  an  intertrigo. 
Cleanliness  is  to  be  secured  by  ablutions  with  soft  water 
and  a  bland  soap,  frequent  change  of  diapers  in  infants,  the 
immediate  removal  of,  and  protection  against,  irritating 
discharges,  and  the  use  of  a  simple  dusting  powder  (zinci 
oxidi,  3iJ5  pulv.  sem.  lycopodii,  3vj)-  After  the  disease 
has  become  established,  it  is  well  to  keep  the  parts  sepa- 
rated by  the  interposition  of  pieces  of  lint  or  thin  flakes 
of  absorbent  cotton  and  to  apply  a  powder  that  is  some- 
what astringent  (thymol.,  gr.  j;  pulv.  zinci  oleatis,  §j). 
Duhring  advises  diluted  lotio  nigra  in  obstinate  cases.  In 
nearly  all  grades  of  intertrigo  we  have  secured  the  most 
admirable  results  with  Lassar's  paste: 


777 /•;  ERYTIIEMATA  19 

1^ — Acicli  salicylic! gr.  xxx 

Zinci  oxidi, 

Ainyli aa  3vj 

Vaselini 5ij — M. 

Perhaps  a  better  formula  is  the  modification  of  the  above 
suggested  some  years  ago  by  Dr.  G.  H.  Fox: 

]$ — Acidi  salicylici .  gr.  xxx 

Bismuthi  subnitratis, 

Amyli  maidis aa  3vj 

Ung.  aquae  rosse 3ij — M. 

This  paste  should  be  spread  thinly  over  the  involved 
surface.  It  is  not  only  directly  curative  in  its  effects,  but 
also  affords  a  most  admirable  protection  from  irritating 
discharges. 

Malcolm  Morris  advises  the  use  of  narrow  muslin  bags 
containing  starch,  powdered  boric  acid,  or  some  antiseptic 
drying  powder.  When  the  skin,  in  chronic  cases,  has 
become  thick,  the  so-called  lichenification  of  the  French, 
plasters  of  5  or  10  per  cent,  salicylic  acid  may  be  applied, 
or  the  skin  may  be  exfoliated  with  resorcin.  (See  Eczema.) 

ADDITIONAL  PRESCRIPTIONS. 

!$ — Zinci  oxidi 3jss 

Pulv.  camphors? 5ss 

Pulv.  amyli 3vj — M. 

S. — Dusting  powder.  M'Call  Anderson. 

]$ — Pulv.  acidi  borici 5j 

Pulv.  zinci  oxidi 3ij 

Pulv.  talci 3v— M. 

S. — Dusting  powder.  Stelwagon. 

Symptomatic  Erythema.  Description. — When  we  bear 
in  mind  the  anatomical  and  physiological  peculiarities  of 
the  skin,  and  its  intimate  connection  with  the  system  at 
large,  it  is  quite  comprehensible  that  many  morbid  states  of 
the  organism  find  local  expression  in  circulatory  derange- 
ments of  the  integument.  One  of  the  commonest  of  these 
disturbances  is  a  superficial  erythematous  inflammation. 
Certain  general  diseases,  e.  y.,  variola,  diphtheria,  cholera, 


20  INFLAMMATIONS 

meningitis,  vaccinia,  etc.,  are  often  preceded,  accompanied, 
or  followed  by  erythematous  rashes. 

More  or  less  transitory  inflammations  of  the  skin  are 
known  to  occur  in  consequence  of  the  ingestion  of  various 
drugs  (erythema  medicamentosum). 

One  of  the  most  frequent,  and,  at  the  same  time,  one  of 
the  most  important  in  a  negative  way,  of  these  sympto- 
matic erythemas  is  the  form  commonly  called  erythema 
infantile,  or  roseola  infantilis.  These  rashes  generally 
assume  the  roseolous  form,  and  are  accompanied  by  a 
slight  elevation  of  temperature  and  perhaps  some  redness, 
without  swelling,  of  the  palate  and  fauces.  They  are  said 
to  be  most  common  over  the  sacral  region  and  buttocks. 

The  symptomatic  passive  hyperemia,  which  may  result 
from  a  variety  of  agencies,  e.  g.,  heat,  cold,  mechanical 
causes,  pathological  states,  etc.,  needs  no  particular  de- 
scription here. 

Treatment. — The  treatment  of  the  various  forms  of 
erythema  mentioned  above  is  the  treatment  of  the  general 
conditions  upon  which  they  are  dependent.  Locally,  as 
in  the  so-called  idiopathic  rashes,  the  use  of  dusting 
powders  or  soothing  lotions  is  usually  all  that  is  demanded. 

Erythema  Scarlatiniforme.  Description. — This  is  a 
disorder  in  which  there  is  a  more  or  less  generalized 
erythema,  followed  in  turn  by  peeling  of  the  skin. 

The  disease  is  acute  or  subacute  in  its  course.  In  the 
acute  type  the  eruption  may  be  preceded  by  premonitory 
symptoms  of  fever  and  malaise  lasting  a  day  or  two,  or 
constitutional  disturbances  may  be  absent.  The  fever, 
when  present,  usually  abates  on  the  appearance  of  the  rash, 
or  it  may  continue  for  some  period.  The  rash  is  generally 
scarlatiniform,  but  it  is  occasionally  morbilliform.  The 
mouth,  throat,  and  tongue  may  be  involved,  but  the  latter 
does  not  present  the  strawberry  aspect  of  scarlatina. 
The  eruption  generally  disappears  in  a  few  days.  The 
subsequent  desquamation  may  be  lamellar  or  branny. 
Mackenzie  makes  the  important  statement  that  the  redness 
does  not  disappear  altogether  when  scaling  takes  place, 


THE  ERYTHEMATA  21 

which  distinguishes  this  affection  from  scarlet  fever.  The 
desquamation  is  of  short  duration,  although  we  have  seen 
it  persist  for  some  weeks.  Rarely,  the  hair  falls  out  and 
the  nails  are  left  brittle  and  furrowed. 

The  subacute  type  of  erythema  scarlatiniforme  more 
nearly  approaches  a  true  dermatitis  exfoliativa.  In  these 
cases  the  systemic  reaction  is  less,  the  eruption  more 
completely  covers  the  whole  body,  and  a  given  attack 
may  last  for  days  or  weeks. 

Recurrence  is  the  rule,  although  the  tendency  may 
gradually  disappear.  Neither  form  is  contagious  nor 
epidemic. 

Causes. — The  causes  of  erythema  scarlatiniforme  are 
various,  viz.,  septic  infection,  gonorrhea,  rheumatism, 
malaria,  eating  of  shell-fish  and  spoiled  meats,  and  the 
taking  of  various  drugs.  External  irritations,  as  from 
mercurial  inunctions  and  the  topical  application  of  iodo- 
form,  sometimes  produce  it.  It  may  also  follow  upon 
surgical  operations.  Individual  idiosyncrasy  must  neces- 
sarily play  an  important  role  in  its  etiology. 

Treatment. — The  internal  treatment  consists  in  ascer- 
taining and  removing  the  exciting  cause  of  the  disorder. 
In  the  absence  of  any  special  indications,  or  in  connection 
therewith,  a  good  routine  practice,  in  acute  cases,  is  to 
clear  out  the  bowels  with  a  mercurial  followed  by  saline 
laxatives.  Salicin  in  appropriate  doses  has  seemed  to  us 
beneficial  after  the  purgative.  In  recurrent  cases  a  careful 
scrutiny  of  the  diet  should  be  made,  and  it  should  also  be 
remembered  that  any  drug  may  be  capable  of  exciting  this 
affection  in  predisposed  persons.  We  have  several  patients 
in  whom  quinine  exerts  this  untoward  effect.  In  chronic 
types  of  the  disease,  Payne  recommends  large  doses  of 
quinine  and  the  salicylate  of  sodium,  but  here  also  we 
prefer  salicin  in  10-gr.  doses  three  or  four  times  a  day,  or 
even  in  larger  quantities. 

The  local  treatment  is  usually  simple,  a  dusting  powder 
of  talcum  generally  sufficing  to  allay  the  irritation.  In 
some  instances,  however,  the  itching  and  burning  are 


22  INFLAMMATIONS 

intolerable,  and  recourse  must  be  had  to  antipruritic 
remedies.  The  most  universally  applicable  is  the  com- 
pound zinc  lotion. 

1$ — Zinci  oxidi 3ij 

Pulv.  calaminsc  prsep 9ij 

Glycerin! 5ij 

Liquoris  calcis q.  s.  ad  5iv — M. 

S. — Shake.    Mop  on  the  surface  with  a  soft  rag. 

It  may  be  necessary  to  add  to  this  lotion  from  £  per  cent, 
to  1  per  cent,  of  carbolic  acid,  or  a  suitable  amount  of 
menthol,  the  latter  being  first  dissolved  in  alcohol. 

Erythema  Pernio  (Chilblain).  Description. — Chilblain 
appears  in  the  form  of  dusky  red  or  even  purplish,  ill- 
defined  patches,  affecting  more  especially  the  sides  and 
backs  of  the  toes  and  fingers.  In  a  more  severe  grade 
of  the  affection,  vesico-papules,  vesicles  and  occasionally 
bullse  may  develop.  When  from  friction  or  other  trau- 
matism  the  vesicles  or  blebs  are  broken,  an  ulcerated  chil- 
blain will  result,  with  the  possibility  of  septic  infection. 

The  subjective  symptoms  consist  of  itching,  tingling, 
burning,  and  pain,  usually  worse  at  night.  The  disease 
attacks,  by  preference,  the  young  and  the  aged,  and  par- 
ticularly those  having  a  feeble  circulation  and  of  the 
so-called  strumous  or  lymphatic  habit  of  body,  although 
healthy  persons  are  not  exempt. 

The  disease  occurs  in  winter  time,  and  disappears  on 
the  approach  of  warm  weather.  Seasonal  recurrences  are 
the  rule.  Chilblain,  and  the  peculiar  type  of  disorder 
known  in  England  as  the  "chilblain  circulation"  are 
comparatively  infrequent  in  this  latitude. 

Treatment. — Where  indicated,  tonics,  such  as  iron  ;md 
arsenic,  may  be  prescribed,  and  any  other  measures 
calculated  to  better  the  general  health  and  improve  the 
circulation  may  be  employed.  Stevens  and  others  claim 
unusually  good  results  in  chilblain  from  the  administration 
of  calcium  chloride.  It  is  given  in  extract  of  licorice  in 
from  10- to  13-gr.  doses,  three  times  a  day.  The  feet  and 
hands  should  be  well  protected,  and  tight-fitting  shoes  and 


THE  ERYTHEMATA 


23 


gloves  prohibited.  According  to  Galloway,  local  mas- 
sage is  beneficial  as  a  preventive  measure;  and  the 
same  authority  recommends  that  the  skin  should  be 
kept  free  from  perspiration,  and  some  antiseptic  powder 
(such  as  boric  acid,  50  per  cent.;  siliceous  earth,  25  per 
cent.,  and  powdered  rice  or  starch,  25  per  cent.)  kept 
in  contact  writh  it.  A  small  amount  of  camphor  or 
menthol  will  be  a  grateful  addition  to  such  a  powder. 
In  the  first  stage  of  chilblain  the  strong  counterirritants 
so  often  recommended  are  to  be  avoided,  or  used  very 
cautiously.  Duhring  advises  a  weak  lotion  of  grindelia 
robusta,  or  a  compound  zinc  sulphide  lotion  (zinc  sul- 
phate and  potassium  sulphide,  each  5  gr.  to  1  oz.).  In 
our  experience  the  calamine  and  zinc  lotion,  to  which 
have  been  added  menthol  and  carbolic  acid,  is  very 
satisfactory : 


^ — Mentholis 
Alcoholis 
Acidi  carbolic!    . 
Zinci  oxidi    . 
Pulv.  calaminae  prsep. 
Glycerin! 
Liq.  calcis     . 


q.B. 

5SS 


q.  s.  ad 


3  S3 

9iv 
Sj 

5viij  —  M. 


In  some  instances  the  menthol  and  carbolic  acid  may 
be  omitted  from  this  prescription  and  the  simple  calamine 
and  zinc  lotion  mopped  on  several  times  a  day.  Crocker 
advises  painting  on  later  the  tincture  of  iodine,  which 
may  be  decolorized  for  exposed  parts,  but  he  regards 
the  rubbing  in  of  iodine  vasogen  as  more  effectual.  For 
the  chronic  forms  of  the  disease  there  are  many  remedies, 
mainly  of  a  stimulating  sort.  Among  such  remedies  may 
be  mentioned  painting  with  the  oil  of  peppermint,  pure 
or  diluted  with  glycerin  (1  to  6) ;  Wilson's  liniment  of  the 
white  and  yolk  of  one  egg  and  an  ounce  each  of  spirits 
of  turpentine  and  distilled  vinegar;  soap  liniment,  1  part; 
tincture  of  cantharides,  1  part;  and  a  50  per  cent,  solution 
of  ichthyol. 

If  the  parts  become  broken  or  ulcerated  the  lesions  may 


24  INFLAMMATIONS 

be  dressed  with  oxide  of  zinc  or  boric  acid  salve,  or,  better 
still,  a  10  per  cent,  salve  of  xeroform. 

Cleveland  met  with  success  in  the  use  of  the  x-ray. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Pulv.  camphone gr.  x 

Cretse  preparatae 5j 

Olei  lini 5ij 

Balsami  peruviani n\  xx — M. 

Kaposi. 

!$ — Acidi  nitrici  diluti, 

Aquae  menthse  piperit aa  5ij — M. 

~ty — Ichthyplis, 
Resorcini, 

Tannini aa  o  j 

Aquae 5v — M. 

Boeck. 

1$ — Balsami  peruviani 5j 

Argenti  nitratis gr.  v 

Ung.  spermaceti 5  j — M. 

S. — For  ulcerated  chilblains.  Leistikow. 

]$ — Olei  cajuputi, 

Liq.  ammon.  fort aa     oij 

Lin.  saponis  comp 5iij — M. 

G.  T.  Jackson. 


EXUDATIVE  ERYTHEMATA. 

Erythema  Multiforme.  Description. — Erythema  multi- 
forme  is  an  exudative  affection,  characterized  by  various 
erythematous,  papular,  tuberculous,  vesicular,  bullous,  and 
nodose  lesions.  Preceding  the  eruption  on  the  skin,  certain 
well-marked  constitutional  symptoms  will  often  be  present, 
such,  for  example,  as  a  general  feeling  of  malaise,  sore 
throat,  rheumatoid  pains,  gastric  disturbance,  and  fever. 
Very  often,  however,  the  eruption  will  appear  without  any 
special  accompanying  general  symptoms. 

Sometimes  even  more  formidable  affections  have  been 
observed  in  connection  with  erythema  multiforme,  such  as 
cardiac  inflammations,  pneumonia,  pleurisy,  acute  rheu- 


EXUDATIVE  ERYTHEMATA  25 

matism,  etc.  The  disorder  may  run  its  course  in  a  few 
days  or  persist  for  several  weeks,  or,  finally,  in  rare  in- 
stances, with  repeated  relapses,  endure  for  an  indefinite 
period. 

The  local  subjective  symptoms  consist  of  burning,  itch- 
ing, and  a  feeling  of  tension  in  the  skin.  It  should  be 
remembered  that  while  many  of  the  different  lesions  of 
erythema  multiforme  may  coexist,  or  may  develop  from 
one  into  the  other,  any  one  form  of  the  disease  may  be  alone 
present,  and  remain  as  such  throughout.  To  the  different 
elementary  forms  represented  in  the  group  have  been 
given  the  following  names:  erythema  annulare,  erythema 
iris,  erythema  gyratum,  erythema  marginatum,  erythema 
papulatum,  erythema  tuberculatum,  erythema  vesiculosum, 
erythema  bullosum. 

It  would  appear  that  this  disease  may  attack  the  mucous 
membrane  of  the  mouth  without  any  evidence  of  cutaneous 
lesions.  The  most  usual  site  of  erythema  multiforme  is 
upon  the  backs  of  the  hands  and  feet,  especially  in  the 
papular  and  tuberculous  forms,  but  it  may  subsequently, 
or  even  from  the  first,  appear  upon  the  rest  of  the  body, 
and  most  abundantly  around  the  painful  joints.  Upon  the 
subsidence  of  the  eruption  slight  desquamation  and  even 
considerable  pigmentation  may  be  observed. 

Herpes  iris  and  erythema  nodosum  properly  belong  to 
this  group  of  disorders,  and  will  accordingly  be  considered 
here. 

Herpes  Iris. — The  eruption  usually  occurs  on  the  backs 
of  the  hands  and  feet,  although  the  mucous  membranes 
may  be  affected.  The  disease  consists  essentially  of  a 
vesicular  lesion  situated  on  an  erythematous  base;  the 
further  evolution  of  this  lesion,  its  enlargement,  its  sub- 
sequent absorption,  the  development  of  other  vesicular  or 
erythematous  rings,  and  the  varying  shades  of  color  thus 
produced  are  the  justification  of  the  term  herpes  iris. 

The  disorder  tends  to  disappear  in  a  few  weeks,  its 
course  being  marked  by  successive  outbreaks.  Herpes 
iris  is  uncommon  in  America. 


26  INFLAMMATIONS 

Erythema  Nodosum. — Before  the  eruption  appears  there 
are  usually  well-pronounced  prodroraic  symptoms  in  the 
shape  of  malaise,  fever,  rheumatoid  pains,  and  sometimes 
sore  throat.  The  lesions  come  out  in  two  or  three  crops, 
and  consist  of  discrete,  .nodose,  painful,  inflammatory 
swellings,  varying  in  size  from  a  small  nut  to  an  egg 
or  larger.  In  some  cases  they  are  fairly  well  defined, 
but  generally  not;  have  a  firm,  tense  feeling  at  first,  but 
become  softer  as  they  decline.  In  the  beginning  they  are 
of  a  red  color,  at  times  reddish  blue,  but  in  the  course  of 
their  evolution  the  lesions  may  assume  the  various  hues 
of  a  bruise.  Suppuration  never  occurs,  although  the 
aspect  of  the  nodes  is  strongly  suggestive  of  pus.  The 
front  of  the  legs  is  the  usual  site  of  the  eruption,  although 
it  may  appear  elsewhere.  There  is  no  doubt  that  for 
erythema  multiforme  in  the  widest  acceptance  of  the  term 
there  are  many  and  diverse  causes.  The  disease  has  been 
noted  in  connection  with  the  acute  specific  fevers  and 
syphilis,  following  vaccination,  after  the  injection  of  serums 
and  antitoxins,  following  the  ingestion  of  foods  and  drugs, 
as  an  accompaniment  of  septic  processes,  and  above  all 
in  the  rheumatic,  and  we  should  also  add  as  one  of  the 
expressions  of  la  grippe. 

The  etiology  of  herpes  iris  is  similar  to  that  of  erythema 
multiforme,  although  seasonal  changes,  especially  spring 
and  autumn,  seem  in  a  greater  degree  to  influence  its 
occurrence.  Crocker  regards  gout  as  a  factor  of  impor- 
tance. In  our  own  experience,  which  agrees  with  that  of 
Mackenzie,  erythema  nodosum  is  in  many  cases  associated 
with  the  rheumatic  diathesis,  although  it  does  occur  in 
connection  with  infectious  diseases  and  after  the  taking 
of  drugs,  such  as  the  preparations  of  iodine  and  the  coal-tar 
derivatives. 

Treatment. — There  can  of  course  be  no  internal  treatment 
of  universal  application  for  erythema  multiforme;  besides, 
the  disease  usually  tends  to  spontaneous  recovery  in  a 
few  days.  The  rational  method  of  management  is  to 
discover  the  direct  or  indirect  cause  of  the  disease  and 


EXUDATIVE  ERYTHEMATA  27 

remove  it  if  possible.  Villemin's  recommendation  of 
giving  30  gr.  of  iodide  of  potassium  daily  has  not  proved 
of  any  value  in  our  hands. 

If  a  rheumatic  tendency  is  present,  Crocker  advises 
salicin  or  salicylate  of  sodium  in  15-gr.  doses  three  times 
a  day.  When  the  disease  is  a  complication  of  la  grippe, 
the  benzoate  of  sodium  in  the  following  formula,  which 
we  owe  to  the  late  Dr.  W.  C.  Glasgow,  is  of  good  service: 

1$ — Sodii  benzoatis 5iij 

Spt.  ammon.  aromat 3vj 

Aquse q.  s.  ad  5iij — M. 

S. — Dessertspoonful  in  carbonated  water  every  two  hours. 

In  the  anemic,  iron  combined  with  an  aperient  seems 
useful.  In  dispensary  practice  Startin's  mistura  ferri  acida 
may  be  prescribed: 

I$— Magnesii  sulphatis  .  .      .      .      3ss 

Ferri  sulphatis 


Acidi  sulphurici  diluti 
Sodii  chloridi 
Infus.  quassise    . 


.      .      .      6iJ 

OSS 

q.  s.  ad     3iv — M. 


S. — Tablespoonful  in  half  a  glass  of  water  a  half-hour  before 
breakfast. 

This  mixture  is  very  disagreeable,  and,  therefore,  among 
the  more  fastidious  some  more  palatable  preparation  may 
be  employed,  such,  for  example,  as  a  granular  effervescing 
sulphate  of  magnesium,  followed  by  iron  after  meals.  A 
combination  of  drugs  devised  by  Rachford,  of  Cincinnati, 
for  migraine,  has,  in  our  hands,  fully  met  most  of  the  indi- 
cations present  in  erythema  multiforme.  It  is  now  put  up 
in  the  form  of  a  granular  effervescing  salt  of  which  each 
dessertspoonful  contains  the  following  ingredients: 

1$ — Sodii  sulphatis gr.  xxx 

Sodii  salicylatis gr.  x 

Magnesii  sulphatis gr.  1 

Lithii  benzoatis gr.  v 

Tincturac  nucis  vomicir TT^VJ — M. 

In  cases  of  erythema  multiforme  where  no  special 
causal  indications  for  treatment  are  to  be  discovered, 
Norman  Walker  regards  sulphur,  given  internally,  as  of 


28  'INFLAMMATIONS 

particular  value.  In  cases  of  severe  vesication  of  the 
mucous  membrane  of  the  mouth  Whitfield  gives  the  B.  P. 
cocaine  lozenge  and  the  carbolic  acid  lozenge  together,  the 
former  being  divided  into  four  parts  and  limited  to  one 
daily. 

In  the  recurrent  tonsillitis  often  seen  in  connection  with 
erythema  multiforme  we  are  in  the  habit  of  ordering  the 
following  application  made  to  the  tonsils: 

1$ — Acidi  carbolic! n\xx 

Glyceriti  acidi  tannici 5iv — M. 

S. — Apply  with  a  cotton  swab. 

This  preparation  should  be  applied  nightly  for  many 
months,  and  even  quite  young  children  can  be  taught  to 
swab  their  own  tonsils.  We  are  fully  persuaded  of  the  great 
value  of  this  application  in  the  prevention  of  tonsillitis  and 
the  ills  that  accompany  that  disease. 

Erythema  Elevatum  Diutinum. — Under  this  title 
Crocker  describes  a  rare  form  of  skin  disease  in  which  are 
present  erythematous,  raised,  and  persistent  lesions  situated 
on  the  dorsal  and  palmar  surfaces  of  the  fingers,  the  elbow- 
joints,  and  buttocks.  The  lesions  are  nodules  from  a  small 
pea  to  bean  size,  of  a  pink  color  at  first,  but  later  taking  on  a 
purplish  hue.  In  the  beginning  the  nodules  are  convex, 
but  afterwards  show  a  tendency  to  coalesce  into  lobed 
infiltrations  and  flat,  elevated  plaques.  In  severe  cases, 
however,  distinct  nodular  tumors  are  present.  The  growths 
are  firm  and  painless.  All  of  Crocker's  cases  were  females, 
and  all  were  children  or  young  adults.  Crocker  regards 
gout  and  acute  rheumatism  as  etiological  factors,  and  con- 
siders the  growths  as  analogues  of  rheumatic  nodules.  In 
a  typical  case  that  we  saw  together  the  patient  was  a  young 
girl,  the  subject  of  rheumatism  and  recurring  tonsillitis. 
Some  months  later  she  contracted  a  severe  diphtheria  and 
received  several  large  doses  of  antitoxin,  whereupon  the 
nodules  speedily  and  entirely  disappeared.  In  less  than  a 
year  they  reappeared,  but  did  not  attain  their  former  size, 
and  soon  again  disappeared  spontaneously.  Whether  the 


ERYSIPELAS  29 

diphtheria  or  the  antitoxin  bore  any  causal  relation  to  the 
disappearance  of  the  lesions  is  a  matter  of  speculation. 

Treatment. — The  treatment  is  regarded  as  unsatisfactory. 
Crocker  suggests  arsenic  internally  and  the  local  applica- 
tion of  liquor  carbonis  detergens.  In  the  case  referred  to 
above,  we  advised  salicin  internally  and  the  local  appli- 
cation to  the  tonsils,  every  night  for  months,  of  the  glycerite 
of  tannin  and  carbolic  acid  mixture  mentioned  under 
erythema  multiforme. 


ERYSIPELAS. 

Description. — Erysipelas  is  an  acute,  contagious  inflam- 
mation of  the  skin  caused  by  the  streptococci  of  Fehleisen 
or  other  microorganisms,  and  characterized  by  certain 
well-pronounced  local  and  general  symptoms. 

The  disease  may  be  conveniently  divided  into  the  simple, 
or  cutaneous,  and  phlegmonous  forms  of  the  malady. 
Before  the  local  disorder  appears  there  is  generally  some 
degree  of  feverishness  or  even  a  distinct  chill,  followed  by 
elevation  of  temperature.  The  degree  of  the  fever  and  its 
duration  will  depend  upon  the  severity  of  the  local  mani- 
festation. The  disease  is  apt  to  commence  about  one  of 
the  mucocutaneous  outlets  of  the  body,  such  as  the  nostrils, 
angles  of  the  mouth,  the  eyelids,  especially  the  inner 
canthus,  the  meatus  of  the  ear,  or  it  may  begin  in  a  mole  or 
wart.  The  initial  spot  is  of  a  rosy-red  color,  and  this 
gradually  enlarges  and  creeps  forward  on  the  skin  with  a 
border  that  is  sharply  defined  from  the  contiguous  healthy 
parts,  and  is  appreciably  elevated.  The  affected  surface  is 
swollen,  especially  in  regions  where  there  is  much  loose 
cellular  tissue,  e.  g.,  under  the  eyes,  is  hard  to  the  touch, 
presents  a  tense  and  shining  appearance,  and  after  a  while 
the  rosy  redness  is  replaced  by  a  duskier  hue,  which  may 
in  severe  cases  become  livid.  If  the  inflammation  is  very 
active,  vesicles  and  blebs  form  over  the  patch,  which,  at 
first  clear,  finally  become  semipurulent  and  dry  up  into 


30  INFLAMMATIONS 

crusts.  If  the  contents  of  the  blebs  are  hemorrhagic  it 
must  be  looked  upon  as  of  unfavorable  omen. 

As  the  process  advances,  the  redness  of  the  peripheral 
extending  portion  will  maintain  its  integrity,  but  the  cen- 
tral area  will  begin  to  fade.  Sometimes  it  may  be  noted 
that  the  outlying  parts  of  the  skin  will  display  rounded, 
reddish  patches,  that  become  gradually  merged  into  the 
original  lesions,  indicating,  as  has  been  generally  supposed, 
the  implication  of  the  lymphatics  in  the  spread  of  the  dis- 
ease. The  affection  may  spread  widely,  the  whole  surface 
of  the  body  being  involved,  or  it  may  take  in  only  a  limited 
region.  Inflammation  of  the  lymphatic  vessels  and  glands 
is  also  present,  and  this  symptom  may  be  apparent  even 
before  the  outbreak  on  the  skin.  The  subjective  sensa- 
tions experienced  by  the  patient  are  generally  those  of 
itching,  tingling,  burning  and  a  feeling  of  great  tension. 
Spontaneous  pain  may  be  entirely  absent,  but  the  parts 
may  feel  quite  sore  to  the  touch,  and  in  some  cases  marked 
hyperesthesia  is  present.  The  degree  of  fever  will  depend 
to  a  great  extent  upon  the  local  inflammation,  and  its 
disappearance  coincides  with  the  subsidence  of  the  latter. 
At  the  conclusion  of  the  local  process  desquamation  in 
large  or  small  scales  ensues.  Erysipelas  occurs  in  all 
grades  of  severity,  and  the  process  may  last  from  a  day  or 
more  to  three  weeks  or  even  longer.  Sometimes  one  attack 
is  speedily  followed  by  another,  and  in  a  very  mild  form  of 
the  disease,  occurring  on  the  face,  relapse  develops  with 
great  frequency. 

Phlegmonous  erysipelas  is  a  much  more  severe  variety 
of  the  disease,  and  differs  from  the  simpler  form  in  the 
greater  intensity,  both  local  and  general,  of  the  process  as 
a  whole.  Purulent  infiltration  and  sloughing  of  the  tissues 
generally  occur. 

Prognosis. — The  prognosis  of  cutaneous  erysipelas  is 
generally  favorable;  but  serious  complications  may  arise 
in  the  simplest  cases,  and  the  gravity  of  the  disease  is 
increased  if  it  occur  in  connection  with  preexisting  dis- 
orders. Erysipelas  of  the  head  and  neck  may  prove 


ERYSIPELAS  31 

dangerous  from  cerebral  complications,  or  implication  of 
mucous  surfaces. 

Treatment. — In  mild  cases  of  the  disease  internal  medi- 
cation is  rarely  called  for;  in  more  severe  attacks  the 
strength  of  the  patient  must  be  kept  up  by  suitable  nourish- 
ment, and,  when  adynamic  symptoms  set  in,  by  appro- 
priate stimulation.  The  tincture  of  the  chloride  of  iron  has 
been  looked  upon  as  almost  a  specific,  given  in  large  doses, 
from  20  to  60  minims,  every  few  hours,  day  and  night.  It 
must  be  said  that  experience  as  to  its  utility  widely  differs. 
Da  Costa  extolled  the  fluidextract  of  jaborandi,  or  pilo- 
carpine  |  gr.  hypodermically,  but  warned  against  its  use 
in  debilitated  subjects,  or  those  having  a  weak  heart. 
Aconite  and  belladonna  have  their  adherents.  Quinine 
has  again  recently  been  brought  forward  as  almost  a 
specific.  Phenacetin  is  valuable  when  the  fever  is  high. 
Injections  of  antistreptococcic  serum,  about  10  c.c.,  have 
been  given  in  serious  cases,  with  apparently  favorable 
results.  As  in  all  diseases  that  run  a  variable  course,  the 
results  of  treatment,  both  local  and  internal,  in  erysipelas, 
are  very  variously  interpreted,  and  the  sources  of  fallacy 
are  numerous. 

The  greatest  number  of  local  applications  have  been 
employed,  but  lack  of  space  forbids  their  enumeration. 
The  disease  apparently  may  be  jugulated  by  many  reme- 
dies. We  believe  the  best  plan  is  to  use  some  preparation 
that  will  thoroughly  protect  the  part  from  all  sources  of 
external  irritation,  and  that  will  give  the  most  comfort  to 
the  patient.  Among  such  remedies  may  be  mentioned  the 
white  paint  applications  of  Barwell,  the  use  of  flexible 
collodion,  and  the  chalk  ointment  of  Duckworth.  This 
latter  is  made  by  mixing  together  equal  parts  of  benzoated 
lard  and  prepared  chalk,  the  lard  being  first  melted,  and 
then  adding,  to  each  ounce  thus  prepared,  %  drachm  of  pure 
carbolic  acid.  This  should  be  thickly  smeared  on,  and 
covered  writh  a  piece  of  borated  lint.  An  application 
recommended  by  Unna,  and  which  we  have  found  service- 
able, is  as  follows: 


32  INFLAMMATIONS 

R- — Ichthyolis, 

Athens aa     3j 

Collodii  flex 3ij— M. 

S. — Apply  with  a  camel's-hair  brush. 

The  same  drug  may  be  used  in  an  aqueous  solution  of 
10  to  25  per  cent,  or  in  the  form  of  an  ointment  in  the 
same  strength.  Credo's  ointment  has  also  been  found  of 
service. 

White  highly  recommends,  in  facial  erysipelas,  a  lotion 
of  carbolic  acid  1  drachm,  to  alcohol  and  water  of  each  8 
ounces.  This  should  be  applied  on  cloths  and  renewed 
every  alternate  hour.  A  poultice  made  by  dipping  a  thin 
layer  of  absorbent  cotton  in  a  1\  per  cent.,  solution  of 
carbolic  acid  makes  one  of  the  most  agreeable  and  useful 
applications  in  erysipelas.  The  cotton  should  be  covered 
with  rubber  tissue.  Among  the  mechanical  modes  of 
treatment  may  be  mentioned  compression  with  adhesive 
straps  along  the  extending  border  of  the  disease,  and  the 
Kraske-Riedel  scarification  method.  Efforts  at  limiting 
the  spread  of  erysipelas  by  solutions  of  nitrate  of  silver, 
tincture  of  iodine,  etc.,  are  perhaps  only  useful  in  those 
cases  that  naturally  limit  themselves.  Finsen's  negative 
phototherapy  has  been  used  here  as  in  smallpox. 

ADDITIONAL  PRESCRIPTIONS. 

R- — Acidi  borici 5j 

Acidi  carbolici gr.  xx 

Resorcini gr.  x  \v 

Alcoholis, 

Aquae aa     5j — M. 

S. — External  use.  Stelwagon. 

R- — Acidi  tannici, 

Camphoric aa  oss 

Athens 3v— M. 

S. — External  use.  Jesner. 

1^ — Ichthyolis gr.  xxx-xl 

Resorcini ,~ss 

Ung.  hydrargvri T>i\ 

Adipis  lame  hydrosi ov — M. 

S. — External  use.  Roswell  Park. 


PELLAGRA  33 

1$ — Extract!  grindelise  fluidi 5j 

Aquae 5xv — M. 

S. — Apply  on  cloths  and  allow  to  evaporate. 


ERYSIPELOID. 

Description. — According  to  Rosenbach,  erysipeloid  is  a 
disease  due  to  wound  infection  with  foul  animal  matter. 
It  is  oftenest  found  in  butchers,  dealers  in  fish,  cooks, 
tanners,  etc.,  and  is  usually  observed  upon  the  hands. 

The  affection  begins,  with  some  degree  of  itching,  as  a 
red  spot  that  gradually  advances  over  the  surface,  but  as 
it  extends  peripherally,  the  central  portion  undergoes 
involution,  and  in  this  way  rings  and  half-circles  are  pro- 
duced. The  lesion  is  but  slightly  elevated,  although  clearly 
defined  against  the  healthy  skin.  The  surface  over  which 
the  disease  process  has  marched  is  left  apparently  normal, 
and  shows  no  desquamation  or  other  secondary  effects. 
Erysipeloid  is  without  systemic  reaction,  and  tends  to 
spontaneous  recovery  in  one  or  two  weeks.  Elliott  recom- 
mends, as  a  perfectly  satisfactory  treatment,  the  application 
of  diachylon  ointment  (unguentum  vaselini  plumbicum),  to 
which  has  been  added  15  per  cent,  to 25  percent,  ichthyol. 
Other  remedies,  such  as  salicylic  acid,  formalin,  perman- 
ganate of  potassium,  pyrogallol,  and  the  mercurials  may 
also  be  noted  as  useful. 


PELLAGRA. 

Definition. — An  endemic  constitutional  disease  present- 
ing erythema,  followed  by  scaling,  infiltration,  pigmenta- 
tion, and,  later,  atrophy;  together  with  gastro-intestinal, 
nervous,  and  other  general  phenomena. 

Description. — Three  stages  are  generally  described: 
First  Stage. — Malaise,  lassitude,  debility,  and  low  spirits 
are  followed  by  erythema  on  the  backs  of  the  hands  and 
3 


34  INFLAMMATIONS 

feet,  neck  and  face,  developing  within  twenty-four  hours 
and  usually  persisting  from  ten  to  twenty  days,  when 
scaling  commences.  Sometimes  there  is  thickening  and 
pigmentation  without  preceding  redness.  There  may  be 
vesicles,  blebs,  and  petechise. 

The  broad,  thick,  dark  scales,  on  detaching  expose  a 
coffee-and-milk  pigmentation.  The  infiltration  and  dark- 
ening of  the  skin  become  more  marked  after  each  attack, 
until  after  several  seasons  the  thickening  gives  place  to 
atrophy,  the  skin  assuming  the  aspect  of  old  age. 

Each  year  with  the  approach  of  winter  the  symptoms 
disappear,  to  return  with  increased  severity  with  the  fol- 
lowing spring. 

Second  Stage. — Pigmentation  increases  and  the  skin 
becomes  excoriated  and  fissured,  and  moist  or  scaly.  There 
are  anemia,  ptyalism,  anorexia,  thirst,  nausea,  indigestion, 
abdominal  pain,  and  diarrhea.  The  tongue  is  red  and 
splits.  Later  there  supervene  emaciation,  weakness,  fever, 
insomnia,  sad  dreams,  and  vertigo,  followed  by  headache 
and  backache,  delirium,  tremors,  loss  of  memory,  and 
melancholia. 

Third  Stage. — The  phenomena  of  the  second  stage 
increase  in  severity  and  insanity  is  common.  Death  may 
come  early.  The  average  duration  of  the  disease  is  five 
years. 

Etiology. — This  disease  is  common  in  certain  country 
districts  of  Italy,  but  only  one  case  has  been  observed  in 
this  country,  so  far  as  we  can  learn.  It  is  attributed  to 
poverty,  with  all  that  that  word  implies,  and  especially  to 
the  use  of  spoiled  maize  as  food,  although  cases  have  been 
observed  in  which  that  factor  could  not  be  invoked.  The 
direct  rays  of  the  sun  seem  to  play  a  part  in  the  production 
of  the  cutaneous  symptoms.  Pisenti  and  Mandolesi  found 
uncinaria  larvae  in  a  number  of  cases  in  which  anemia  was 
a  marked  feature.  Harris  in  this  country  observed  pel- 
lagra-like symptoms  in  a  case  of  uncinariasis.  K.  Ziegler 
obtained  Aspergillus  fumigaius  in  cultures  from  tissues  of 
21  cases  out  of  28. 


FURUNCLE  35 

Prognosis. — The  disease  is  generally  fatal.  Mild  cases 
and  those  that  have  passed  through  only  one  attack  may 
recover. 

Treatment. — More  abundant  food  of  a  nutritious  and 
easily  digested  quality,  abstinence  from  spoiled  maize,  the 
avoidance  of  dampness  on  the  one  hand  and  of  the  direct 
rays  of  the  sun  on  the  other,  proper  ventilation,  and  removal 
if  possible,  from  the  infected  district,  are  the  chief  factors 
that  may  bring  about  a  cure.  Gastro-enteric  symptoms, 
when  present,  call  for  sedative  and  soothing  remedies. 
Bitter  tonics,  iron  and  cod-liver  oil  are  demanded  in  chronic 
cases.  Arsenic  is  sometimes  followed  by  marked  improve- 
ment. Serious  nervous  symptoms  may  call  for  the  use  of 
opium. 

FURUNCLE. 

Description. — A  boil  or  furuncle  is  due  to  an  acute  phleg- 
monous  inflammation  of  the  skin  and  connective  tissue 
surrounding  a  skin  gland  or  follicle,  which  in  turn  is  fol- 
lowed by  suppuration  and  the  extrusion  of  a  central 
slough,  called  the  core. 

The  clinical  symptoms  of  a  boil  are  too  well  known,  and 
too  often  experienced,  to  need  any  further  mention.  Boils 
occur  singly  or  in  groups ;  they  often  come  out  in  successive 
crops,  and  for  long  periods,  constituting  the  conditions 
known  as  furunculosis.  Any  part  of  the  general  surface 
may  be  the  seat  of  attack,  except  the  palms  and  soles,  but 
boils  show  a  marked  predilection  for  the  back  of  the  trunk 
and  neck.  It  is  now  conceded  that  furuncles  are  due  to 
the  entrance  of  pus  cocci  (Staphylococcus  albus  et  aureus) 
into  the  openings  of  the  skin  glands  or  hair  follicles. 

Boils  are  more  frequently  encountered  in  men  than  in 
women,  and,  as  a  rule,  are  observed  less  in  infants  than  in 
boys  and  young  adults.  Local  irritation,  due  to  the  chafing 
of  the  skin  from  rough  garments,  decubitus,  etc.,  often 
give  rise  to  solitary  boils. 

Furunculosis  of  the  nape  of  the  neck  is,  we  think,  mainly 


36  INFLAMMATIONS 

due  to  infection  from  the  soiled  fingers  of  barbers  or  from 
the  dirty  implements  of  their  trade  (see  especially  car- 
buncle). Sweaters,  swimming  drawers  and  other  garments 
worn  by  men  in  training  and  in  athletic  games,  often 
become  infected  and  set  up  boils  in  unusually  healthy 
subjects. 

Furuncles  complicate  many  diseases  of  a  depressing 
nature,  such  as  diabetes,  variola,  typhoid  fever,  etc. 
Severe  pruritic  disorders,  which  occasion  scratching 
with  the  finger-nails,  are  often  complicated  or  followed  by 
boils,  as,  for  example,  eczema  and  scabies. 

Medical  men,  especially  those  engaged  in  making  surgi- 
cal dressings,  have  appeared  to  us  to  be  especially  prone 
to  a  furunculosis  of  the  extensor  surfaces  of  the  arms  from 
the  wrist  to  the  elbow. 

Prognosis. — The  prognosis  of  boils  is  usually  good. 
When  they  occur  in  crops,  even  if  the  patient  is  otherwise 
well,  they  may  prove  very  persistent,  and  even  appreciably 
depress  the  general  health.  When  boils  appear  in  con- 
nection with  serious  systemic  disorders,  their  presence 
materially  increases  the  sufferings  of  the  patient. 

Treatment. — In  all  cases,  particularly  those  of  a  chronic 
sort,  it  is  wise  to  investigate  the  hygienic  surroundings  and 
general  health  of  the  patient.  If  sugar  or  albumin  be 
found  in  the  urine,  suitable  measures  should  be  instituted 
at  once  for  the  treatment  of  those  conditions. 

All  local  sources  of  irritation  should  be  ferreted  out  and 
removed.  Old  smoking  jackets,  sweaters,  and  even  collars 
and  cuffs  of  the  outer  garments  should  be  cast  away  or 
disinfected. 

Now  that  we  know  that  boils  are  due  to  direct  local 
inoculation,  although  it  may  be  granted  that  the  condition 
of  the  soil  is  an  important  factor,  there  is  much  less  pre- 
scribing of  the  multitude  of  remedies  supposed  to  be  "  good 
for  the  blood." 

The  dyspeptic,  the  constipated,  the  gouty,  the  anemic, 
and  the  strumous  should  each  receive  appropriate  treat- 
ment. The  food  and  drink  should  be  properly  regulated. 


FURUNCLE  37 

Leredde  recommends  Carlsbad  salts  for  obese  people  who 
are  gross  eaters. 

There  are  certain  remedies  that,  given  internally,  are 
said  to  have  some  specific  effect  on  boils.  Yeast  is  an  old- 
fashioned  "  cure"  that  sometimes  seems  to  have  a  decided 
effect.  An  adult  may  take  a  hajf-wineglassful  night  and 
morning.  Sulphide  of  calcium  may  perhaps  have  some 
germicidal  properties  when  taken  internally,  but  it  should 
be  given  in  much  larger  doses  than  is  common.  Dilute 
sulphuric  acid  in  10-to20-drop  doses,  well  diluted,  is  much 
esteemed  by  some  physicians. 

Medicines  that  improve  the  general  nutrition,  thus 
rendering  the  tissues  more  resistant  to  local  infection,  are 
of  unquestioned  value  in  furunculosis,  e.  g.,  arsenic,  iron, 
cod-liver  oil,  the  hypophosphites  and  the  syrup  of  the 
lactophosphate  of  lime. 

Recently  A.  E.  Wright  has  claimed  good  results  in  acne, 
furunculosis,  and  sycosis,  from  the  inoculations  of  staphylo- 
coccus  vaccine.1  For  a  further  elucidation  of  this  sub- 
ject see  "The  Opsonic  Method"  in  Part  II. 

In  the  management  of  the  boil  itself,  an  effort  should  be 
made  to  prevent,  or  at  least  limit,  suppuration.  For  this 
purpose  the  salicylic  acid  plaster  of  L.  Heitzman  is  often 
valuable. 

1$ — Acidi  salicylici 5ij 

Empl.  saponis Sij 

Em  pi.  diachyli 5j — M. 

S. — Spread  on  cotton  cloth. 

Bidder,  following  Hueter,  employs  a  2  per  cent,  solution 
of  carbolic  acid,  with  which  he  makes  one  or  more  injections 
according  to  the  size  of  the  boil.  This  is  a  good  method, 
but  painful.  Iodine  may  be  applied  in  successive  layers, 
and  allowed  to  encroach  a  little  on  the  healthy  skin. 

An  electrolytic  needle  inserted  into  a  commencing  boil 
will  often  abort  it.  If  a  hair  occupies  the  centre  of  a 
furuncle  it  should  be  plucked.  Stelwagon  recommends  an 

1  British  Medical  Journal,  1904,  p.  1075. 


38  INFLAMMATIONS 

ointment  or  aqueous  solution  of  ichthyol,  25  per  cent, 
strength,  kept  constantly  applied,  as  sometimes  of  value 
as  a  jugulator.  Boric  acid  may  be  similarly  employed. 

Unna's  mercuric-carbolic  plaster  often  succeeds  in 
aborting  a  boil;  but  if  suppuration  has  already  begun, 
nothing  succeeds  so  well  in  hastening  it.  A  hole  should  be 
cut  in  the  centre  of  the  plaster  corresponding  to  the  apex 
of  the  boil. 

When  boils  are  very  painful  the  common  practice  is  to 
apply  a  flaxseed  poultice  to  relieve  the  tension,  but  unless 
the  poultice  is  rendered  antiseptic  by  the  addition  of  car- 
bolic acid  it  is  apt  to  favor  reinfection  in  the  vicinity. 
Much  better  is  the  "  antiseptic  poultice,"  consisting  of  a 
number  of  layers  of  gauze  saturated  in  a  hot  1  per  cent, 
carbolic  lotion  and  covered  with  oiled-silk  or  gutta-percha 
tissue.  The  following  ointment  serves  all  the  purposes  of  a 
poultice,  and  helps  to  allay  the  pain. 

1$ — Xeroformi 3j 

Ung.  vaselini  plumbic! ^j — M. 

S. — Spread  on  cotton  cloth  or  patent  lint. 

Powdered  iodoform  is  more  decidedly  analgesic,  but 
some  patients  show  an  idiosyncrasy  in  regard  to  it. 

Phenacetin  in  doses  of  5  gr.  or  more  at  night  is  rer 
markably  efficacious  in  allaying  restlessness  and  pain. 
It  acts  much  better,  we  think,  than  opium. 

If  incisions  are  urgently  demanded,  the  skin  may  be 
anesthetized  by  a  spray  of  ethyl  chloride.  After  the  boil 
has  burst,  the  resulting  cavity  should  be  dressed  on  ordinary 
surgical  principles. 

It  is  very  necessary,  particularly  when  boils  are  multiple, 
to  cover  the  intervening  and  surrounding  skin  with  the 
following  paste: 

1$ — Acidi  borici 5j 

Zinci  oxidi .  5j 

Pulv.  amyli 5"j 

Vaselini q.  s.  ad  3j — M. 

Washing  the  skin  with  green  soap  and  warm  water,  and 
mopping  on  a  lotion  of  bichloride  of  mercury,  1  to  1000, 


FURUNCLE  39 

often  puts  a  stop  to  reinfection.  Alcohol  is  a  thoroughly 
efficient  and  harmless  antiseptic  for  this  purpose. 

Clean  clothing  should  be  put  on  frequently,  and  the 
patient  should  be  warned  against  carrying  infection  to 
other  parts  with  his  fingers.  Boils  in  the  external  auditory 
canal  and  at  the  borders  of  the  lids  (styes)  usually  fall 
under  the  care  of  the  otologist  and  ophthalmologist,  but 
one  of  us1  has  shown  elsewhere  that,  as  regards  styes, 
they  frequently  are  due  to  infection  from  a  seborrheic 
scalp,  and  that  their  recurrence  may  be  prevented  by 
proper  treatment  of  the  scalp  itself,  namely,  with  green- 
soap  shampoos  and  an  ointment  of  sulphur  and  salicylic 
acid.  (SeeSeborrhea.)  The  usual  local  treatment  is  to  be 
employed  at  the  same  time.  A  condition  of  furunculosis  on 
the  back  of  the  neck  is  a  source  of  great  annoyance  and  is 
most  difficult  to  treat  satisfactorily.  We  believe  that  for 
boils  in  this  situation  the  source  of  infection  is  often  found 
in  the  barber  shop,  and  consequently  we  are  in  the  habit 
of  directing  patients  to  see  to  the  thorough  disinfection  of 
the  barber's  tools.  (For  further  details  see  Carbuncle.) 
If  the  patient  has  seborrhea  of  the  scalp,  this  should  be 
treated,  and  under  any  circumstances  the  hair  should 
be  frequently  shampooed.  Locally,  the  neck  should  be 
washed  twice  daily  with  a  sulphur,  camphor,  and  balsam 
of  Peru  soap,  and  afterward  mopped  with  a  boric  acid 
lotion,  Vleminckx's  solution  diluted  as  in  acne  (see  Acne), 
or  alcohol. 

In  intractable  cases  the  parts  may  be  axrayed  with  hope 
of  success,  taking  care  to  protect  the  scalp  with  a  suitable 
shield.  Stelwagon  suggests  the  arc  light.  The  opsonic 
treatment  above  mentioned  may  be  a  last  resort. 

ADDITIONAL  PRESCRIPTIONS. 

]$ — Sulphuris  sublimati gr.  jss 

Pulv.  camphorse gr.  J 

For  one  cachet. 

S. — Take  three  daily.  Robin. 

1  Hardaway. 


40  INFLAMMATIONS 

T$ — Beta-naphthol, 

Bismuthi  subnitratis, 

Magnesii  carbonatis aa  gr.  ivss 

Ft.  chart.  No.  1. 

S. — One  powder  every  four  hours.  LeGendre 

]} — Tr.  arnicse 3j 

Acidi  tannici 3ss 

Pulv.  acaciae 5ss — M. 

S. — External  use. 

1$ — Acidi  carbolici gr.  v-x 

Ext.  ergotse  fld 3  j 

Pulv.  amyli 3j 

Zinci  oxidi 3ss 

Ung.  aq.  rosse 5j — M. 

S. — Apply  spread  on  absorbent  cotton  Bulkley. 


CARBUNCLE. 

Description. — A  carbuncle  is  an  acute  phlegmonous 
inflammation  that  terminates  in  sloughing  of  the  tissues. 
A  carbuncle  differs  from  a  boil  in  being,  as  a  rule,  solitary; 
in  the  depth  of  the  original  point  of  attack,  in  the  multi- 
plicity of  the  foci  simultaneously  involved,  in  its  flatness, 
its  slower  growth,  greater  pain,  and  profounder  ulceration. 

Etiology. — The  etiology  of  the  carbuncle  is  similar  to 
that  of  the  boil,  and  probably  concerns  the  same  micro- 
organisms. Carbuncle  most  often  occurs  in  those  who 
are  in  poor  health  from  other  causes,  but  this  rule  is  by  no 
means  invariable.  There  is  an  especial  association  between 
carbuncle  and  diabetes  mellitus. 

Elsewhere  one  of  us1  has  called  attention  to  the  fre- 
quency with  which  carbuncles  are  acquired  in  barber  shops, 
although  we  think  the  profession  has  but  little  realized  the 
importance  of  this  source  of  contagion.  We  have  seen 
many  cases  of  carbuncle,  in  which  the  evidence  of  this 
transmission  was  to  us,  at  least,  indisputable.  While,  of 
course,  carbuncles  may  be  got  in  a  variety  of  ways,  and 
may  be  situated  in  a  variety  of  places,  being  due  to  the 

1  Hardaway,  St.  Louis  Courier  of  Med.,  December,  1903. 


CARBUNCLE  41 

same  microorganisms  that  produce  boils,  it  is  a  note- 
worthy fact  that  women,  who  do  not  frequent  barber  shops, 
rarely  suffer  from  them,  and  that  the  lesions  occur  in  the 
majority  of  cases  on  those  parts  of  the  body  most  exposed 
to  infection,  e.  g.,  the  nape  of  the  neck,  and  not  so  infre- 
quently on  the  bearded  face.  Since  carbuncles  are  most 
formidable  and  dangerous  affections,  especially  in  diabetics 
and  the  debilitated  generally,  the  possibility  of  transmis- 
sion by  the  barber  should  be  remembered  and  precautions 
taken  to  prevent  it. 

Prognosis. — When  a  carbuncle  of  ordinary  size  occurs 
in  a  person  of  robust  health  the  prognosis  is  good.  With 
increase  in  size  of  the  carbuncle  the  outlook  becomes 
graver.  In  the  aged  and  debilitated,  carbuncle  is  always  a 
dangerous  affection.  When  the  disease  occurs  about  the 
head  the  prognosis  seems  to  be  more  doubtful  than  for 
carbuncle  of  other  regions. 

Treatment. — Since  experience  has  convinced  us  that  a 
certain  proportion  of  carbuncles,  especially  of  the  neck  and 
face,  are  contracted  in  barber  shops,  it  becomes  a  matter 
of  simple  obligation  to  see  that  the  public  is  protected  from 
this  source  of  contagion,  and  this  duty  becomes  the  more 
urgent  in  the  case  of  persons  known  to  be  suffering  from 
diabetes.  If  the  laws  enacted  by  various  boards  of 
health  could  be  enforced,  many  of  the  evils  connected 
with  the  barber  shop  would  be  materially  abated.  Un- 
fortunately, however,  in  many  places  no  such  laws  exist, 
and  one  must  endeavor  to  supply  their  place  by  private 
effort. 

For  many  years  we  have  been  in  the  habit  of  recom- 
mending that  each  patron  of  a  barber  shop  provide  himself 
with  a  box  containing  his  own  brush  and  comb,  a  small 
package  of  absorbent  cotton,  and  a  5  per  cent,  solution  of 
carbolic  acid.  It  being  assumed  that  the  barber  has  first 
washed  his  hands,  he  moistens  a  bit  of  cotton  with  the 
solution  and  then  thoroughly  wipes  off  his  shears;  as  the 
clippers  cannot  be  cleaned  by  ordinary  methods,  their  use 
should  be  forbidden.  The  barber's  utensils  being  cleaned 


42  INFLAMMATIONS 

and  the  use  of  one's  own  brush  and  comb  insisted  upon,  one 
is  at  least  in  a  degree  free  from  the  risk  of  getting  the  more 
common  contagious  disorders.  Time  and  again  we  have 
seen  these  simple  measures  put  a  stop  to  recurrent  follicu- 
litis  of  the  neck  and  other  pustular  diseases. 

A  carbuncle  once  established,  there  is  often  present  con- 
siderable depression  of  the  vital  forces,  which  will  neces- 
sitate a  supporting  and  stimulating  treatment  from  the 
outset.  Morphine  or  phenacetin  may  be  required  for 
the  pain.  The  use  of  sulphide  of  calcium  is  highly 
recommended  by  some  authorities  on  account  of  its 
presumed  power  of  limiting  suppuration.  A  variety  of 
methods  for  the  local  treatment  of  carbuncle  has  been 
advised. 

Hypodermic  injections  of  a  10  per  cent,  solution  of 
carbolic  acid  in  oil  or  glycerin,  at  several  points  in  the 
lesion  will  sometimes,  made  early,  abort  a  carbuncle. 
Cotton  compresses  soaked  in  a  5  per  cent,  solution  of 
carbolic  acid,  and  covered  by  rubber  tissue,  generally 
afford  relief  and  often  seem  to  limit  the  inflammation. 
Unna's  carbolic  acid  and  mercury  plaster-mull  is  unques- 
tionably valuable  in  the  same  way;  and  the  same  may  be 
said  for  an  ointment  of  1  drachm  of  iodoform  or  xero- 
form  to  1  oz.  of  unguentum  vaselini  plumbicum.  lehthyol 
applied  pure  or  diluted  with  2  or  3  parts  of  water  is  also 
advocated.  Crocker  states  that  if  a  carbuncle  is  seen  at  an 
early  stage  a  solution  of  carbolic  acid,  1  to  30,  should  be 
injected  subcutaneously  all  around  the  lesion,  and  that  if 
this  is  done  thoroughly  the  extension  is  almost  invariably 
stopped.  The  old-fashioned,  and  still  popular,  linseed- 
meal  poultice  should  never  be  employed;  the  lead  oint- 
ment with  iodoform  or  xeroform  may  be  applied  instead, 
or  boric  lint  wrung  out  in  hot  water  may  be  put  on  and 
covered  with  rubber  tissue  or  oiled  silk. 

Stel wagon's  suggestion  of  the  cupping  glass  to  empty  a 
discharging  carbuncle  impresses  us  favorably. 

In  recurring  cases  recourse  may  be  had  to  the  opsonic 
method,  q.  v. 


MALIGNANT  PUSTULE  43 

In  carbuncles  of  a  grave  character,  with  marked  systemic 
reaction,  it  is  idle  to  waste  time  with  palliative  measures. 
In  such  cases  drastic  surgical  interference  is  urgently 
demanded,  such  as  erasion  or  complete  extirpation.  Wood 
and  Taylor  claim  especially  good  results  with  the  injection 
of  a  saturated  solution  of  pure  carbolic  acid  through  the 
openings  into  the  sloughing  tissues.  After  the  sloughs 
have  come  away  or  been  removed,  the  resulting  ulcer 
should  be  treated  on  the  usual  surgical  principles. 


MALIGNANT  PUSTULE. 

Description. — Malignant  pustule  or  anthrax  is  a  gan- 
grenous affection  of  the  skin  usually  appearing  upon  an 
exposed  part,  generally  the  hand  or  face,  and  due  to  inocu- 
lation with  the  Bacillus  anthracis,  derived  immediately  or 
mediately  from  an  animal  infected  with  splenic  fever. 
External  anthrax  occurs  chiefly  in  butchers,  tanners,  and 
woolsorters — persons  who  come  in  contact  with  the  flesh 
and  hides  of  infected  animals.  Consequently,  in  suspicious 
cases  the  occupation  of  the  patient  should  be  considered. 

Generally,  from  one  to  three  days  after  inoculation,  a  red, 
itching,  or  burning  papule  forms,  upon  which  a  bulla  or  pus- 
tule soon  develops.  The  bulla  or  pustule  ruptures,  exposing 
a  black,  gangrenous  surface.  A  crop  of  vesicles  appears 
around  the  border  of  the  slough,  the  skin  being  red,  indu- 
rated and  greatly  swollen,  while  the  neighboring  lymphatic 
vessels  and  ganglia  become  enlarged,  the  latter  sometimes 
suppurating.  The  gangrenous  process  may  spread  rapidly, 
being  accompanied  by  the  symptoms  of  acute  septicemia, 
and  may  cause  death  in  one  to  six  days.  In  favorable 
cases  the  slough  is  cast  off,  and  the  loss  of  tissue  replaced 
by  a  cicatrix. 

Treatment. — The  most  radical  treatment  consists  in 
early  excision  combined  with  the  administration  of  tonics 
and  stimulants.  Injection  of  iodine  and  carbolic  acid 
beneath  the  eschar,  and  various  methods  of  cauterization 


44  INFLAMMATIONS 

have  also  been  recommended.  On  the  other  hand,  K. 
Mueller,  D.  W.  Montgomery,  and  others  recommend  an 
almost  entire  avoidance  of  active  local  interference  and 
especially  of  excision.  Blue  ointment  may  be  smeared 
over  the  affected  surface,  and  the  patient  given  suitable 
diet  and  freely  stimulated  with  alcohol. 


EQUINIA. 

Description. — This  disorder,  commonly  called  glanders, 
is  an  infectious  disease  due  to  inoculation  with  the  Bacillus 
mallei.  The  disease  has  a  great  variety  of  forms  and 
symptoms,  which  cannot  be  considered  in  this  place.  If 
the  specific  agent  has  gained  entrance  through  a  lesion  of 
the  skin,  local  pain  is  experienced,  together  with  erisipelas- 
like  redness  of  the  parts  and  involvement  of  the  neighboring 
lymphatics. 

Meanwhile,  the  initial  ulcer  enlarges,  discharges  a  sani- 
ous,  offensive  pus,  and  takes  on  a  chancroidal  aspect.  Later 
on,  erythematous  spots  come  out  on  the  skin,  which 
become  converted  into  variola-like  pocks,  and  sometimes 
into  large  blebs.  The  pustules,  which  are  about  the  size 
of  a  pea,  burst,  and  pour  out  an  offensive,  sanguino- 
purulent  discharge.  On  the  other  hand,  large,  projecting 
tumors  and  abscesses  may  develop,  that  are  at  first  hard  and 
painful,  but  subsequently  become  doughy,  fluctuate,  and 
break  down  into  extensive,  corroding  ulcers  that  penetrate 
the  tissues  and  expose  the  bones  and  tendons.  The  various 
skin  lesions  may  occupy  the  entire  surface,  which,  together 
with  swellings  of  the  joints,  present  a  most  horrible  picture 
of  suffering.  In  addition  to  lymphatic  involvement  at  the 
site  of  inoculation,  the  vessels  and  glands  in  other  parts 
of  the  body  become  implicated,  and,  according  to  circum- 
stances, may  undergo  resolution,  or  else  suppurate  and 
produce  other  ill-conditioned  ulcers.  The  cutaneous  phe- 
nomena may  develop  in  from  twenty-four  to  forty-eight 
hours,  or  they  may  not  appear  for  from  two  to  four 


IMPETIGO  CONTAGIOSA  45 

weeks,  being  preceded  by  a  nasal  discharge  and  certain 
ill-defined  general  and  local  symptoms. 

In  chronic  glanders,  if  the  specific  agent  has  entered 
some  exposed  portion  of  the  body,  the  local  phenomena 
are  the  same  as  in  the  acute  form.  The  constitutional 
symptoms  are  also  similar  wherever  the  port  of  entry.  It 
would  seem,  however,  that  the  stress  of  the  disease  in  the 
chronic  type  is  laid  upon  the  skin  and  certain  other  tissues 
of  the  body,  whereas  intranasal  lesions  are  absent  in  at 
least  one-half  of  all  cases.  They  are,  on  the  contrary, 
invariably  present  at  some  time  in  the  course  of  acute 
and  subacute  cases. 

Treatment. — In  addition  to  the  immediate  destruction 
of  the  inoculated  surface,  when  it  can  be  found  and  reached, 
by  strong  caustics  or  the  actual  cautery,  the  general  and 
local  treatment  should  be  based  on  the  ordinary  principles 
of  medicine  and  surgery.  However,  there  is  but  little  hope 
from  any  treatment  in  acute  cases.  The  chronic  form  of 
the  disorder  may  last  from  a  few  months  to  ten  or  eleven 
years  (Bellinger),  and  is  fatal  in  about  one-half  the  cases. 
Injections  of  mallein  have  been  given  in  recent  years  with 
some  asserted  success.  Doubtless  sterilized  emulsions  of 
the  dead  bodies  of  the  bacilli,  administered  according  to 
the  opsonic  method  (see  Part  II),  would  be  efficacious. 


IMPETIGO  CONTAGIOSA. 

Description. — The  relationship  of  the  various  impetigos 
to  each  other,  still  a  questio  vexata  among  pathologists,  can 
safely  be  ignored  by  the  clinician,  since  the  treatment  is 
practically  the  same  for  all  forms  of  pyodermia.  In  this 
place  will  be  briefly  given  some  of  the  more  striking 
features  of  what  is  called  impetigo  contagiosa. 

The  eruption  on  the  skin  begins  in  the  form  of  small, 
discrete,  acuminate  vesicles  that  enlarge  to  the  size  of  a 
split  pea  or  twenty-five-cent  piece.  The  contents,  which 
are  at  first  serous,  soon  become  seropurulent.  In  a  few 


46  INFLAMMATIONS 

days  the  lesions,  which  are  flat  or  even  umhilicated,  dry 
to  thin,  granular,  straw-colored  crusts  that,  owing  to  the 
absence  of  an  inflammatory  halo,  have  the  appearance  of 
being  "stuck  on."  When  the  crusts  fall  off  the  surface 
is  red,  as  if  from  a  burn,  but  scarring  does  not  occur. 
Instead  of  beginning  invariably  as  vesicles,  the  lesions  are 
sometimes  vesicopapular,  vesicopustular  or  frankly  pustu- 
lar. In  adults  the  lesions  may  not  develop  but  remain 
as  papules.  Itching  is  not  marked.  The  mucous  mem- 
branes may  be  occasionally  involved.  The  eruption  is 
most  prone  to  attack  the  face  and  hands,  and  may  con- 
sist of  several  or  many  discrete  lesions,  or,  when  closely 
set,  they  may  coalesce  and  form  patches. 

Sometimes  there  may  be  a  slight  ephemeral  fever  pre- 
ceding the  outbreak,  but  other  cases  occur  in  which  it  is 
absent.  Other  varieties  of  impetigo  contagiosa  are  the 
bullous,  in  which  large  pemphigoid  blebs  are  present, 
which  often  run  together,  producing  gyrate  lesions  and, 
sometimes  healing  in  the  centre,  extend  peripherally  by 
undermining  the  skin  with  fluid;  and  the  circinate,  which 
presents  a  narrow,  creeping  border  in  which  vesication  is 
barely  apparent.  The  condition  may  strikingly  resemble 
ringworm.  The  disease  attacks  children  by  preference, 
is  contagious,  and  occasionally  occurs  quasi-epidemically. 
Fatal  cases  have  been  reported  in  infants  by  Bray  ton, 
by  one  of  us,1  and  others.  It  runs  its  course  in  from  two 
to  three  weeks,  although  it  may  be  kept  up  indefinitely  by 
repeated  auto-inoculation.  A  rare  variety  of  the  bullous 
form,  oftenest  encountered  in  children,  is  that  in  which 
a  single,  large  lesion  appears  upon  a  finger,  its  dense 
epithelial  roof  keeping  the  infection  localized. 

In  our  early  experience  with  impetigo  contagiosa  the 
disease  was,  as  just  stated,  practically  confined  to  children, 
but  during  the  past  five  or  six  years  the  majority  of  our 
patients  have  been  male  adults,  the  disease  appearing 
on  the  face  and  having  usually  been  contracted  in  the 
barber  shop. 

1  Grindon. 


IMPETIGO  CONTAGIOSA  47 

Treatment. — The  management  of  the  ordinary  type  of 
the  disease  as  it  occurs  in  children  is  simple  and  effectual. 
After  the  crusts  have  been  removed  by  soaking  in  olive 
oil,  the  following  salve  should  be  kept  constantly  on  the 
affected  parts: 

1$ — Hydrargyri  ammoniati er.  v-x 

Vaselini 3ij 

Lanolini 5vj 

A  weak  xeroform  ointment  also  acts  well. 

In  pruritic  cases,  in  which  the  disease  is  conveyed  from 
place  to  place  by  scratching,  Stelwagon  advises  the 
application  several  times  a  day  of  a  lotion  consisting  of  a 
saturated  solution  of  boric  acid,  to  each  ounce  of  which 
may  be  added  5  gr.  of  resorcin  and  the  same  amount  of 
carbolic  acid.  In  extensive  gyrate  cases  Crocker  recom- 
mends sponging  the  surface  once  thoroughly  with  1  to 
4000  corrosive-sublimate  solution,  followed  by  boric  acid 
ointment  spread  thickly  on  lint  and  closely  applied.  Ex- 
tensive bullous  forms,  the  so-called  pemphigus  neonatorum, 
when  occurring  with  denudation,  may  be  treated  like  a 
burn.  All  clothing  should  be  removed  and  the  child  should 
be  laid  on  flour,  a  half-inch  thick,  which  is  to  be  changed 
as  often  as  it  gets  moist  from  the  discharge.  Such  sur- 
faces may  also  be  dusted  with  dry  boric  acid  frequently 
renewed.  Another,  and  perhaps  better,  method  is  to  open 
all  bulla3  as  soon  as  formed  and  to  wipe  them  out 
thoroughly,  as  well  as  the  whole  surface,  with  95  per  cent, 
alcohol.  One  of  us1  successfully  treated  a  bedridden 
woman  of  90  years,  whose  body  was  covered  with  many 
hundred  bullse,  by  this  means,  and  has  elsewhere  reported 
another  case  observed  in  an  adult,  in  every  respect  similar 
to  so-called  pemphigus  neonatorum. 

A  somewhat  different  method  of  treatment  is  to  be  fol- 
lowed when  the  disease  attacks  the  bearded  face  of  the 
adult.  Here  daily  shaving  is  to  be  advised,  but  unless  the 
shaving  brush,  soap,  and  cup  are  thoroughly  disinfected 

1  Grindon. 


48  INFLAMMATIONS 

after  each  operation  of  shaving,  the  disease  is  apt  to 
be  kept  up  by  repeated  inoculations.  To  overcome  this 
difficulty  we  direct  the  patient  to  procure  some  one  of  the 
shaving  creams  that  are  sold  in  collapsible  tubes  and 
to  discard  the  usual  utensils  altogether. 

As  a  local  application  white  precipitate  may  be  pre- 
scribed in  the  strength  of  10  to  20  gr.  to  1  oz.  or  a  weak 
sulphur  and  salicylic  acid  ointment,  a  10  per  cent,  xero- 
form  ointment,  or,  perhaps,  most  efficacious  of  all,  citrin 
ointment  diluted  one-half  with  the  ointment  of  oxide 
of  zinc. 

For  tfte  superficial  whitlow  not  infrequently  met  with  in 
children  suffering  from  impetigo  contagiosa,  5  per  cent,  or 
10  per  cent,  of  xeroform  in  unguentum  vaselini  plumbicum 
gives  good  results.  The  salve  should  be  spread  on  cotton 
cloth  or  patent  lint,  and  kept  in  place  by  a  bandage  or 
finger  stall. 

In  so-called  simple  impetigo  the  crusts  should  be  re- 
moved, and  a  salicylic  acid  ointment  of  10  to  20  gr.  to 
1  oz.  of  vaselin  applied. 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Acidi  salicylici, oss 

Vaselini 5j 

Zinci  oxidi, 

Amyli aa     5ss 

S. — Apply  after  removal  of  crusts.  Lassar. 

IJ — Ting,  hydrargyri  nitratis 5j-5iij 

Creaspti rr\y 

Vaselini Sj 

Payne. 

ECTHYMA. 

Description. — In  this  disorder,  which  most  authorities 
refuse,  properly  enough,  to  recognize  as  a  distinct  disease, 
are  to  be  observed  large,  flat,  somewhat  flaccid  pustules  of 
a  yellowish  or  yellowish-red  color,  varying  in  size  from 
a  ten-cent  piece  to  a  silver  quarter-dollar,  and  sur- 


ECTHYMA  49 

rounded  by  a  well-defined  areola.  Desiccation  is  rapid, 
and  when  the  brownish  crusts  are  removed,  a  slightly 
excoriated  surface  is  seen,  which  is  covered  with  a 
yellowish  secretion  slightly  tinged  with  blood.  Marked 
pigmentation  usually  follows  healing.  The  legs  and  thighs 
are  the  usual  seat  of  the  eruption.  Males  are  almost 
exclusively  attacked.  It  is  closely  allied  to  impetigo  and 
f  urunculosis,  being  the  result  of  inoculation  with  pus  organ- 
isms, and,  like  the  affections  just  mentioned,  may  appear 
in  broken-down  subjects,  but  also  in  persons  apparently  in 
good  health,  besides  following  in  the  wake  of  local  irrita- 
tions of  all  sorts. 

Prognosis. — The  prognosis  of  ecthyma  is  always  good, 
recovery  generally  taking  place  in  a  comparatively  short 
time  under  a  judicious  treatment. 

Treatment. — In  persons  who  are  obviously  suffering 
from  debility,  or  who  present  symptoms  indicating  any 
disorder  of  the  general  system,  the  physician  should  order 
appropriate  tonics,  and  address  his  remedies  to  the  organ 
or  organs  at  fault.  The  diet  should  be  regulated,  cleanli- 
ness enforced,  a  sharp  lookout  kept  up  for  pediculi,  and 
the  general  hygienic  surroundings  improved,  if  possible. 

After  removal  of  the  crusts  an  ointment  of  white  pre- 
cipitate, 15  gr.  to  1  oz.,  gives  prompt  relief.  As  in 
impetigo  contagiosa,  the  surrounding  skin  should  be  dis- 
infected either  with  a  bichloride  solution  or  one  of  boric 
acid  and  resorcin,  or  with  95  percent,  alcohol.  (See  Im- 
petigo Contagiosa.)  When  the  lesions  are  sluggish  the 
following  application  acts  beneficially: 

1^ — Xeroform gr.  xxiv-xlviij 

Vaselini §ij 

Lanolini 3vj — M. 

Obstinate  cases  might  call  for  the  employment  of  the 
opsonic  method.  (See  Part  II.) 


50  INFLAMMATIONS 


POMPHOLYX. 

Description. — This  disease,  also  called  dysidrosis  (Fox) 
and  cheiropompholyx  (Hutchinson),  consists  of  an  erup- 
tion of  vesicles  and  bullse  on  the  hands  and  feet.  Before 
an  outbreak  occurs  there  is  usually  some  amount  of  burn- 
ing and  tingling,  soon  followed  by  the  appearance  of  small, 
deeply  seated  vesicles  along  the  sides  of  the  fingers  and  on 
the  palms,  but,  according  to  Crocker,  in  bad  cases  the 
whole  hand  may  be  involved.  Somewhat  more  rarely 
the  feet  may  be  attacked.  When  the  lesions  are  grouped 
they  run  together  and  form  blebs.  The  hand  is  then  stiff 
and  painful.  The  lesions  usually  vary  in  size  from  a  pin- 
head  to  a  small  bean.  Generally,  within  ten  days  to 
two  weeks,  the  contents  of  the  vesicles  are  absorbed,  the 
epidermis  is  exfoliated,  and  all  that  is  left  of  the  affec- 
tion is  the  dry,  red  skin  where  the  eruption  had  been 
situated.  Fox  found  that,  in  some  instances,  this  red, 
scaly  condition  became  chronic,  but  certainly  in  most 
cases  the  cuticle  soon  becomes  normal.  Recurrences  are 
common,  and  it  is  said  that  women  are  more  frequently 
attacked  than  men.  Pompholyx  is  practically  symmetri- 
cal. Hyperidrosis  is  a  common  symptom  and  all  observers 
are  agreed  it  is  a  disease  of  debility. 

Prognosis. — The  immediate  attacks  are  always  curable, 
but  the  tendency  to  relapse  is  difficult  to  overcome. 

Treatment. — Internal  treatment  consists  in  the  adminis- 
tration of  tonics,  especially  iron  and  arsenic,  attention 
to  diet,  and  the  general  regulation  of  the  habits  of  the 
patient.  The  following  prescription  answers  very  well  in 
many  cases: 

J$ — Strychninsc  sulphatis gr.  j-ij 

Ext.  gentianae q.  s. — M. 

Acidi  arseniosi gr.  j 

Quininse  sulphatis oj 

Ferri  sulphatis oij 

Div.  in  pil.  No.  Ix 

S. — One  pill  three  times  a  day. 


POMPHOLYX  51 

Robinson  regards  arsenic  pushed  to  its  physiological 
limit  as  almost  as  efficacious  as  the  same  drug  is  in 
pemphigus.  In  persons  manifestly  suffering  from  so- 
called  debility,  with  poor  circulation  and  cold,  clammy 
hands  and  feet,  a  mixture  of  the  following  kind  has  appeared 
to  be  useful : 

1^ — Glyceriti  hypophosphitis, 

Syrupi  calcis  lactophosphatis    .      .      .      .     aa      5"j 
S. — Two  teaspoonfuls  in  water  before  meals. 

Locally,  soothing  and  somewhat  astringent  remedies 
are  indicated.  While  the  vesicles  or  blebs  are  intact  (and 
they  never  rupture  spontaneously)  the  zinc-calamine  lotion 
is  to  be  recommended. 

1$ — Zinci  oxidi 5ss 

Pulv.  calaminse  pra?p 9iv 

Glycerin! 5j 

Liquoris  calcis 5vij — M. 

Cheese-cloth  cut  in  suitable  strips  should  be  thoroughly 
wet  with  this  lotion  and  kept  in  place  by  a  bandage.  If 
there  be  much  burning  and  tingling,  a  small  amount  of 
carbolic  acid  and  menthol  may  be  added  to  the  lotion. 
Afterward,  when  the  skin  is  red,  scaling,  and  tender,  it  is 
advisable  to  apply  the  modified  diachylon  ointment  spread 
on  lint  and  neatly  bound  on  the  parts. 

Other  methods  of  treatment  recommended  are  diluted 
black  wash,  weak  compound  zinc  lotion,  weak  salicylic 
acid  paste  (Duhring),  oleate  of  zinc,  or  lead  ointment 
(Crocker),  and  frequent  bathing  in  sublimate  solution 
(1  to  4000),  with  the  application  either  of  a  salicylic  oint- 
ment or  a  2  per  cent,  salicylic  dusting  powder  (Walker). 
The  last-named  authority  suggests  the  use  of  formalin  or 
resorcin  soap  in  the  intervals  of  the  attacks  to  strengthen 
the  resisting  power  of  the  skin. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Resorcini 5ss 

Ackli  salicylici gr.  xv 

Ol.  ricini 5ss 

Tr.  benzoini 5iv 

S. — Paint  on  several  times  daily.  Leistikow. 


52  INFLAMMATIONS 

1$ — Mentholis gr.  ij 

Acidi  salicylic! gr.  x 

Emplastri  plumbi, 

Emplastri  saponis aa  ojss 

Petrolati 3v 

S. — Spread  on  lint  and  apply  as  a  plaster.  Stelwagon. 


HERPES  FACIALIS. 

Description. — This  is  an  acute,  non-contagious  inflam- 
matory disorder  which  appears  in  the  form  of  one  or  more 
groups  of  vesicles.  The  eruption  is  commonly  called  fever 
blisters.  The  vesicles  come  out  suddenly,  being  preceded, 
however,  by  a  sensation  of  burning,  tingling,  or  itching. 
The  contents  of  the  lesions  are  clear  at  first,  but  in  a  day 
or  two  become  puriform,  although  when  the  light-brown 
crusts  fall  off  the  skin  usually  shows  no  sign  of  scarring. 
The  favorite  sites  of  the  eruption  are  the  lips,  the  angles 
of  the  mouth,  and  the  face  generally  below  the  mouth. 
The  vesicles  also  may  be  seated  on  the  mucous  membrane 
of  the  mouth,  cheeks,  tonsils,  uvula,  pharynx,  larynx, 
conjunctiva,  and  cornea.  Herpes  facialis  is  generally 
symptomatic  of  febrile  disorders,  and  is  often  ushered  in 
with  a  chill  and  rise  of  temperature;  in  other  instances, 
however,  it  is  the  result  of  gastro-intestinal  disturbance  or 
of  simple  external  irritation. 

Treatment. — In  the  majority  of  cases  no  internal  treat- 
ment is  required;  but  when  relapse  is  frequent,  it  is  well  to 
enquire  into  the  condition  of  the  digestive  tract,  and  to 
entertain  the  possibility  of  malarial  infection.  The  local 
management  of  the  disorder  is  simple.  As  suggested  by 
Winfield,  spirits  of  camphor,  or  a  powder  composed  of 
equal  parts  of  biborate  of  soda  and  camphor,  may  be 
rubbed  into  the  beginning  patch  and  thus  prevent  the 
appearance  of  the  vesicle.  It  is  sometimes  possible  to  abort 
a  forming  vesicle  on  the  lip  by  repeatedly  rubbing  over  it 
a  piece  of  borax.  When  the  vesicles  are  well  out  it  is 
important  to  prevent  their  premature  rupture,  and  this 
can  be  accomplished  by  mopping  on  the  zinc  and  calaniiuc 


HERPES  PROGENITALIS  53 

lotion,  or,  better  still,  by  painting  over  the  parts  with  a  thin 
layer  of  Pick's  linimentuni  exsiccans  (q.  v.)  to  which  has 
been  added  10  per  cent,  oxide  of  zinc.  When  the  lesions 
are  about  the  angle  of  the  mouth,  especially  in  children, 
the  patch  should  be  protected  with  the  preparation  just 
mentioned  or  a  thin  layer  of  flexible  collodion;  otherwise 
the  irritation  of  saliva,  etc.,  may  produce  a  sore  of  con- 
siderable size. 

Walker  believes  that  the  tendency  to  recurrence  may 
eventually  be  overcome  by  painting  the  lesions  in  every 
attack  with  a  solution  of  silver  nitrate  in  spirit  of  nitrous 
ether  1  scruple  to  1  oz. 

HERPES  PROGENITALIS. 

Description. — Herpes  occurring  about  the  genitals  is 
sufficiently  characteristic  to  demand  a  special  description. 
While  very  annoying  in  itself  it  derives  additional  impor- 
tance from  the  possibility  of  confusing  it  with  more  serious 
affections  of  these  parts.  Usually,  before  the  eruption 
makes  its  appearance,  the  patient  is  apt  to  feel  some  slight 
burning  or  tingling  wrhich  is  presently  followed  by  an  erup- 
tion of  vesicles,  varying  in  size  from  a  pin's  head  to  that 
of  a  small  pea,  and  in  number  from  two  to  three  to  a  dozen, 
but  more  commonly  five  or  six.  The  order  of  frequency  as 
to  situation  is  as  follows:  the  sulcus,  the  inner  surface  of  the 
foreskin,  the  glans,  the  margin  or  edge  of  the  prepuce,  and, 
lastly,  the  shaft  of  the  penis.  The  vesicles,  when  situated 
on  the  delicate  mucous  membrane,  speedily  rupture,  and 
show  merely  little  eroded  spots,  circularly  disposed,  and 
seated  on  a  reddened  base.  Sometimes  the  little  erosions 
run  together.  On  the  skin  the  vesicles,  as  in  herpes  facialis, 
do  not  readily  rupture,  but  become  opaque,  and  dry  into  a 
brownish  crust,  which  upon  becoming  detached  leaves 
a  slightly  reddened  surface.  The  disease  also  occurs  in 
women,  affecting  the  mucous  surfaces  of  the  pudendum, 
as  well  as  the  outer  portion  of  the  labia  and  the  mons 
veneris. 


54  INFLAMMATIONS 

It  is  generally  held  that  herpes  progenitalis  is  most  apt 
to  occur  in  persons  who  have  suffered  from  antecedent 
venereal  disease ;  but  other  factors  undoubtedly  enter  into 
its  etiology  and  must  be  considered  in  the  prophylactic 
treatment.  Such,  for  example,  are  excessive  venery,  injudi- 
cious eating  and  drinking,  gouty  and  rheumatic  tendencies, 
and  various  external  irritations. 

Treatment. — So  far  as  regards  the  general  management 
of  this  disease  the  physician  should  endeavor  to  discover 
and  remove  if  possible  all  predisposing  causes.  Internally, 
Wolff  recommends  the  long-continued  use — 6  to  8  months 
— of  arsenic.  Winfield  states  that  in  the  gouty  or  rheu- 
matic, a  full  course  of  antirheumatic  or  antigouty  remedies 
will  prevent  recurrence. 

In  the  local  treatment  care  should  be  taken  to  avoid 
cauterization  of  the  lesions,  since  such  treatment  is  harm- 
ful, often  producing  deep  ulcers  that  may  persist  for  weeks, 
and  it  also  leads  to  great  confusion  in  diagnosis.  Dusting 
the  surfaces  with  a  little  carbonate  of  magnesia  and  keeping 
them  apart  by  dry  lint  is  often  all  that  is  necessary.  Occa- 
sionally, if  the  surface  has  become  somewhat  angry,  a 
bismuth  ointment  (1  drachm  to  1  oz.)  is  efficacious.  If 
suppuration  should  occur  from  undue  irritation,  a  5  per 
cent,  or  10  per  cent,  xeroform  ointment  is  demanded. 
Should  there  be  coincident  tenderness  of  the  inguinal 
glands,  rest  in  bed,  and  the  application  of  an  ointment 
of  iodoform  (2  drachms  to  1  oz.)  over  the  sensitive  glands, 
will  prove  useful.  A  redundant  prepuce  may  be  cut  off 
with  some  hope  of  success,  but  we  have  seen  this  procedure 
fail  of  any  permanent  result  in  many  cases. 

Finally,  in  the  hope  of  increasing  the  resistance  of  the 
tissues,  daily  applications  of  a  3  per  cent,  tannin  or  a  5 
per  cent,  alum  lotion  may  be  prescribed  (Wolff). 

Stelwagon  advises  the  daily  use  of  a  descending  galvanic 
current  of  \  to  2  ma. 


HERPES  ZOSTER  55 


HERPES  ZOSTER. 

Description. — Herpes  zoster,  zona,  or,  popularly,  shingles, 
is  an  inflammatory  disease  of  the  skin,  which  consists  of 
grouped  vesicles  on  a  reddened  base.  The  most  frequent 
seat  of  the  disease  is  around  the  trunk  following  the  dis- 
tribution of  the  intercostal  nerves;  hence  the  term  zoster, 
a  belt,  and  the  word  shingles,  from  a  corruption  of  cingu- 
lum,  a  girdle.  It  is  necessary  to  remember,  however,  that 
while  zoster  is  most  frequent  on  the  trunk,  it  may  occur 
elsewhere  on  the  body,  and  presents,  more  or  less  exactly, 
the  same  symptoms  as  when  it  attacks  the  more  classical 
locality. 

Before  the  outbreak  of  the  eruption,  the  patient  will 
usually  experience  considerable  neuralgic  pain.  The 
eruption  occurs  in  the  shape  of  little  erythematous  patches, 
upon  which  for  a  short  while  in  the  beginning,  minute, 
grouped  papules  are  to  be  detected,  that,  however,  speedily 
develop  into  distinct  vesicles.  The  fully  established  dis- 
order is  very  characteristic. 

Taking  a  general  view  of  the  eruption,  it  is  seen  to  be 
made  up  of  clusters  of  large,  opaque  vesicles  that  have  an 
arrangement  not  unlike  bunches  of  grapes,  only  that  the 
branches  and  twigs  are  hidden  from  sight.  This  is  due  to 
the  fact  that  the  lesions  follow  the  course  of  a  nerve  or  its 
offshoots.  The  vesicles  vary  in  size  from  a  pin-head  to 
a  pea,  those  that  come  out  last  generally  being  the  smaller. 
Often  they  appear  in  large  numbers,  in  which  case  one  or 
more  vesicles  may  coalesce  to  form  a  large  bleb.  Their 
contents  are  at  first  clear,  but  eventually  grow  turbid  and 
puriform.  The  vesicles  do  not  rupture  spontaneously, 
are  more  or  less  umbilicated,  and  in  the  course  of  ten  days 
to  two  weeks  dry  up  into  brownish  crusts,  which  upon 
becoming  detached  show  a  reddened  surface,  or  here  and 
there  slight  pits.  The  eruption  is  in  the  vast  majority  of 
cases  unilateral,  which  fact  has  given  rise  to  the  popular 
dea  that,  if  the  lesions  make  the  circuit  of  the  body,  a 


56  INFLAMMATIONS 

fatal  issue  may  be  expected.  The  neuralgic  pain  may 
subside  on  the  outbreak  of  the  vesicles,  but  this  is  not 
usually  the  case,  these  symptoms  often  persisting,  with 
local  burning  sensations,  throughout  the  course;  and,  in- 
deed, the  neuralgia  may  last,  especially  in  old  or  feeble 
persons,  for  months  or  years  afterward.  The  dis<  ;i>< 
rarely  occurs  twice  in  the  same  individual,  but  there  are 
exceptions  to  this  rule. 

There  are  certain  variations  in  the  course  of  the  disease, 
as  outlined  above.  The  eruption  may  run  an  abortive 
course,  no  vesicles  being  produced  at  all.  Sometimes  the 
vesicles  may  become  hemorrhagic.  In  old  or  badly 
nourished  subjects,  or  from  traumatism,  ulceration  of  the 
skin,  and  consequent  deep  scarring  may  result.  Certain 
trophic  disturbances  may  ensue,  and  even  motor  paralysis. 

Herpes  zoster  ophthalmicus  may  be  a  very  serious 
affection.  Vesicles  may  form  on  the  cornea,  which  soon 
rupture;  the  exposed  tissue  takes  on  purulent  infiltration, 
and  pus  is  often  deposited  in  the  anterior  chamber.  Iritis 
is  generally  present.  Permanent  corneal  opacities  are  apt 
to  result. 

Various  names  have  been  applied  to  indicate  the  ana- 
tomical seat  of  the  eruption,  namely,  zoster  capillitii,  zos- 
ter frontalis,  zoster  ophthalmicus,  zoster  facialis,  zoster 
nuchae,  etc.  Chronic  or  relapsing  zosteriform  eruptions 
are  generally  due  to  a  source  of  continuous  reflex  irrita- 
tion and  form  a  distinct  class,  etiologically  considered. 

Barensprung's  discovery  of  changes  in  the  ganglion  of 
the  posterior  root  has  been  confirmed  by  Head  and  Camp- 
bell, who  found  them  invariably  present.  There  was  acute 
inflammation,  frequently  with  hemorrhages  and  destruc- 
tion of  ganglion  cells  and  fibers.  To  this  succeeded  acute 
degeneration,  partial  or  complete,  of  the  posterior  root 
itself,  and  at  times  of  fibers  of  the  posterior  column  of  the 
cord.  Later  sclerotic  changes  were  found  in  the  root,  but 
not  in  the  cord,  probably  on  account  of  the  small  number 
of  fibers  affected.  Similar  changes  occur  in  the  peripheral 
nerves.  They  are,  as  a  rule,  secondary  to  the  lesion  of 


HERPES  ZOSTER  57 

the  ganglion,  although  active  inflammatory  changes  may 
extend  down  from  the  ganglion  and  root  into  the  nerve- 
trunk. 

Prognosis. — The  prognosis  of  zoster  is  usually  good; 
one  may  say  invariably  so  in  young,  healthy  persons,  but 
in  the  broken-down  or  the  aged,  or,  if  the  disease  affect  the 
eye,  a  more  guarded  opinion  should  be  given.  As  deep 
scars  are  sometimes  left,  the  physician  should  warn  the 
patient  of  this  possibility,  lest  they  should  be  attributed 
to  the  remedies  employed. 

Treatment.— It  should  be  borne  in  mind  that  zoster, 
as  ordinarily  encountered,  is  an  acute,  self-limited  disease, 
which,  moreover,  presents  great  variations  in  both  local 
and  constitutional  symptoms.  In  children  it  is  mild  in 
character,  while  in  the  adult,  and  particularly  in  old  people, 
it  is  apt  to  be  severe,  and  leave  behind  persistent  neuralgia. 
Therefore,  with  these  facts  before  us,  it  is  easy  to  put  the 
proper  valuation  on  the  various  so-called  specific  methods 
of  treatment.  We  do  not  believe  that  there  is  any  remedy 
capable  of  aborting  zoster;  but  as  the  disease  is  often  self- 
abortive,  and  always  self-limited,  it  is  clear  that  drugs  often 
secure  undue  credit.  It  is  fair  to  state  that  Thompson, 
Bulkley,  and  others  claim  good  results  in  lessening  the 
severity  of  the  attack  by  administering  the  phosphide  of 
zinc  in  ^  gr.  doses  every  three  hours.  Van  Harlingen  states 
that  it  is  very  efficient  for  the  accompanying  neuralgia. 
For  the  same  purpose  Duhring  advises  ten  or  twelve  cells 
of  the  galvanic  battery.  We  can  confirm  his  observations, 
as  most  decided  mitigation  of  the  pain  may  be  obtained 
in  this  way.  We  pay  no  attention  to  the  direction  of  the 
current.  The  applications  should  be  made  once  or  twice 
a  day,  the  last  one  at  night,  and  should  last  ten  or  more 
minutes  at  each  sitting.  In  adults  it  is  sometimes  necessary 
to  use  morphine  hypodermically,  although  phenacetin,  or 
phenacetin  and  salol,  usually  gives  satisfactory  results. 
Jamieson  is  authority  for  the  statement  that,  if  the  char- 
acter of  the  premonitory  pains  be  recognized  in  time,  a 
blister  over  the  spine  on  the  painful  side  will  partially  or 


58  INFLAMMATIONS 

completely  abort  the  cutaneous  manifestations.  Drink- 
water  recommends  spirit  of  camphor  in  5-minim  doses,  on 
sugar,  three  times  a  day.  In  recurrent  zoster  search 
should  be  made  for  a  source  of  reflex  irritation  such  as  a 
carious  tooth,  or  rib,  osteophytes,  etc. 

There  are  many  local  applications  for  the  relief  of  zoster. 
The  best  in  most  cases  is  the  flexible  collodion,  as  it  eases 
the  pain  and  protects  the  vesicles  from  rupture,  an  accident 
that  is  always  to  be  deplored.  In  adults,  the  following 
combination  is  useful: 

1$ — MorphiniB  sulphatis gr.  v-x 

Collodii  flex 3j — M. 

S. — Paint  over  eruption. 

I^eloir  advised  alcohol,  pure,  or  an  alcoholic  solution  of 
resorcin,  thymol,  and  several  other  drugs  in  the  abortive 
stage,  but  it  is  also  claimed  that  this  method  is  effectual 
in  any  stage  of  the  disease  and  also  in  herpes  simplex. 
Some  of  the  formulae  used  by  Leloir  are  appended : 

1$ — Alcoholis  (90  per  cent.) 3j 

Resorcini gr.  x — M. 

1$ — Alcoholis  (90  per  cent.)      ......      5j 

Mentholis gr.  xv 

Ext.  cannabis  indicae gr.  xxv — M. 

1^ — Alcoholis  (90  per  cent.) 5j 

Ext.  cannabis  indicse gr.  xxv. 

Cocain.  hydrochloridi gr.  vj 

Spiritus  menthse  piperitae n\vj — M. 

These  various  solutions  are  applied  by  means  of  pads 
of  wadding,  and  are  frequently  renewed.  Howard  Morrow 
speaks  well  of  the  use  of  ethyl  chloride  as  a  counterirritant 
for  the  pain  of  zoster.  An  area  of  the  size  of  a  dollar  is 
frozen  at  a  point  where  the  nerve  emerges  from  the  spinal 
column,  and,  although  this  usually  relieves  the  pain  along 
the  entire  nerve,  it  is  better  to  freeze  areas  where  the  pain 
is  localized. 

Dusting  powders  containing  morphine  or  camphor  are 
also  advised.  Smearing  the  surface  thinly  with  vaselin, 
and  then  dredging  on  subnitrate  of  bismuth,  make  an 


HERPES  ZOSTER  59 

agreeable  application.  Ointments  should,  as  a  rule,  be 
avoided.  When,  however,  the  vesicles  have  been  accident- 
ally broken  and  ulcerations  occur,  the  unguentum  vaselini 
plumbicum,  with  or  without  xeroform,  may  be  spread  on 
muslin  and  bound  on  the  parts. 

Meredith  says  that  the  oil  of  peppermint,  both  in  the 
acute  stage  and  for  the  after-pains,  is  an  admirable  remedy. 
Menthol  in  ointment  or  lotion  is  better  still.  In  our  experi- 
ence the  best  remedy  for  the  persistent  neuralgia  that  so 
often  follows  zoster  in  adults  is  the  galvanic  current  applied 
in  the  course  of  the  affected  nerve.  At  the  same  time, 
tonic  treatment,  according  to  the  indications  present, 
should  not  be  neglected. 

Williams  relieved  the  subjective  sensations  in  one  case 
with  x-rays.  Allen  obtained  decided  relief  of  pain  with 
the  high-frequency  current,  ironing  with  the  flat  hammer 
electrode  both  during  the  disease  and  for  the  resulting 
neuralgia. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Quininse  sulphatis 5j 

Morphinac  sulphatis, 

Aciui  arseniosi aa     gr.  jss 

Ext.  aconiti gr.  xv 

Strychninse  sulphatis gr.  j — M. 

Div.  in  pil.  No.  xxx. 

S. — One  pill  three  times  a  day  for  the  persistent  neuralgia  of  zoster. 

S.  D.  Gross. 

1$ — Zinci  phosphidi, 

Ext.  nucis  vomicie aa     gr.  x— M. 

Div.  in  pil.  No.  xxx. 

S. — One  every  two  to  four  hours.  Bulkley. 

1^ — Amyli 3ij 

Zinci  oxidi §j 

Pulv.  camphonc gr.  xv-xlv — M. 

S. — As  a  dusting  powder.  If  there  is  much  pain  15  gr.  pow- 
dered opium  may  be  added.  Head. 

I$— Ichthyol., 

Aquse aa     3j — M. 

S. — External  use.  Head. 


60  INFLAMMATIONS 


REPEATING  NEURALGIC  HERPES. 

One  of  us1  has  called  attention  to  a  condition  intermedi- 
ate between  simple  herpes  and  recurrent  zoster,  in  which  a 
single  group  of  vesicles  occurs  at  intervals  of  a  few  months 
or  a  year,  always  at  an  unvarying  site,  so  that  each  attack 
is  an  exact  copy  or  repetition  of  all  that  have  preceded  it. 
The  condition  occurs  on  the  face,  away  from  mucous 
outlets,  or  on  the  gluteals,  is  preceded  and  sometimes 
accompanied  by  neuralgic  pain,  is  oftenest  seen  in  adults, 
and  continues  to  recur  for  years  without  scarring.  "\Vhcn 
about  the  face,  search  should  be  made  for  such  sources  of 
reflex  irritation  as  septal  spurs,  hypertrophied  turbinates, 
carious  teeth,  or  teeth  which  by  being  misplaced  exert 
undue  pressure  on  each  other,  or  overlapping  protuber- 
ances of  the  gums.  The  gluteal  cases  may  depend  upon 
some  departure  from  the  normal  in  the  rectum  or  anus. 
The  local  measures  recommended  in  simple  herpes  may 
be  used.  Mauriac  has  described  an  allied  condition  as 
herpes  genital  neVralgique. 


PEMPHIGUS. 

Description. — Pemphigus  is  a  chronic,  or  sometimes  acute, 
inflammatory  disease  of  the  skin,  characterized  by  the 
formation  of  variously  sized  bullse  that  appear  in  succc»ivr 
crops.  It  is  a  comparatively  rare  affection.  It  is  difficult 
to  define  pemphigus  with  exactness,  since  many  bullous 
diseases  have  been  classed  under  this  head;  but  it  may  be 
said  that  an  eruption  of  blebs  does  not  necessarily  consti- 
tute a  pemphigus.  As  a  matter  of  clinical  convenience  the 
disorder  may  be  placed  under  the  following  heads:  acute 
pemphigus,  pemphigus  vulgaris,  or  chronic  pemphigus, 
pemphigus  foliaceus,  and  pemphigus  vegetans  (?). 

1  Grindon 


,      PEMPHIGUS  61 

Acute  Pemphigus. — There  undoubtedly  occurs  on  the 
skin  a  bullous  eruption  more  or  less  grave  in  character 
and  of  relatively  limited  duration,  which  goes  by  the  varied 
names  of  epidemic  pemphigus,  pemphigus  neonatorum, 
pemphigus  hystericus,  etc.,  but  we  believe  that  these  condi- 
tions represent  no  substantive  affection,  and  are  only 
expressions  of  septic  processes,  drug  eruptions,  dermatitis 
factitia,  etc.  Fernet  and  others  have  described  an  acute 
pemphigus  occurring  in  butchers  or  persons  engaged  in 
handling  hides,  in  which  there  is  a  history  of  a  trifling 
wound  preceding  the  eruption.  Severe  septic  symptoms 
develop  in  connection  with  the  bullae,  and  after  some 
weeks  the  patient  usually  dies  from  exhaustion. 

Pemphigus  Vulgaris,  or  Chronic  Pemphigus.— Constitu- 
tional symptoms  are  not  observed  in  all  cases  of  chronic 
pemphigus.  As  a  matter  of  fact,  it  would  appear  that  the 
degree  of  systemic  reaction  is  in  indirect  proportion  to  the 
extent  of  the  local  dermatitis. 

The  individual  lesions  consist  of  hemispherical  or  oval 
blisters  of  various  sizes.  At  first  they  come  out  as  little 
transparent  vesicles,  which,  however,  quickly  grow  to  the 
bigness  of  a  pea,  or  go  on  increasing  to  the  size  of  a  walnut 
or  orange,  or  one  or  more  bullse  may  coalesce,  forming  a 
large,  irregular  bleb.  As  a  rule,  however,  the  lesions  vary 
in  size  from  a  hazelnut  to  a  walnut.  The  bullse  may  come 
out  on  unaffected  skin,  or  there  may  be  a  preceding  local 
erythema  at  the  point  of  eruption.  The  lesions  arise 
abruptly,  forming  tense  bladders  filled  with  fluid,  which, 
at  first  clear,  gradually  become  turbid,  sometimes  hemor- 
rhagic,  and  in  some  cases  decidedly  purulent. 

Each  bleb  runs  its  course  in  from  two  to  eight  days. 

At  the  same  time  that  blebs  form  on  the  skin  they  may 
be  encountered  on  the  mucous  membranes  of  the  mouth, 
conjunctiva?,  and  also  in  the  respiratory  and  alimentary 
tracts.  The  characteristic  feature  of  pemphigus  is  the 
manner  in  which  the  disease  is  kept  up  by  successive 
outbreaks. 

Pemphigus  Foliaceus. — The  blebs  are  flaccid,  and  not 
elevated  and  tense  as  in  ordinary  pemphigus.  Their  con- 


62  INFLAMMATIONS 

tents  are  more  or  less  cloudy  from  the  beginning,  and  in 
some  cases  turn  purulent.  The  lesions  are  not  long  lived, 
and  soon  rupture.  When  their  covering  is  pushed  or  slid  oft' 
with  the  finger  the  surface  beneath  is  seen  to  be  moist  from 
the  presence  of  a  nauseous,  sticky  secretion  which  dries 
into  flaky  crusts.  The  disease  spreads  slowly  but  surely, 
and  eventually  the  whole  body  becomes  invaded.  The 
mucous  membrane  of  the  mouth  and  throat  may  be 
affected,  the  nails  ridged  or  even  cast  off,  alopecia  and 
ectropion  develop,  and  the  patient  finally  sinks  from  maras- 
mus. 

Pemphigus  Vegetans. — In  this  disorder  a  mucous  mem- 
brane is  usually  attacked  in  the  beginning,  the  initial 
lesion  being  situated  in  the  mouth  or  pharynx,  or  in  theanus 
or  external  female  genitals,  and  in  the  first-named  localities 
is  often  accompanied  by  much  pain  in  deglutition.  After 
two  or  three  days,  and  without  any  preceding  or  attendant 
general  symptoms,  ordinary  pemphigus  bulla?  begin  to 
come  out  on  the  skin.  The  blebs,  instead  of  drying  up 
in  the  usual  way,  become  excoriated  and  give  off  a  viscid, 
ill-smelling  secretion,  and,  other  blebs  appearing  in  their 
neighborhood,  by  coalescence  form  large,  raw  patches  of 
various  sizes  and  shapes.  The  lesions,  as  a  rule,  show  no 
tendency  to  healing,  but  in  certain  situations,  especially 
where  surfaces  are  in  contact,  become  covered  with  papil- 
lary excrescences  resembling  condylomata.  Superficial 
necrosis  may  occur.  The  disease  pursues  a  chronic  course, 
fresh  crops  of  bulla?  appear,  and  the  patient  finally  suc- 
cumbs to  marasmus  or  dies  from  some  intercurrent  dis- 
order. Some  few  cases  of  recovery  have  been  reported. 

A  somewhat  similar  condition  has  been  described  under 
the  name  of  dermatitis  vegetans,  but  it  differs  considerably 
both  in  its  local  and  its  constitutional  features. 

Prognosis. — The  prognosis  in  pemphigus  is  uncertain, 
a  fact  which  would  be  expected  from  a  consideration  of 
its  varied  etiology.  A  few  cases  of  acute  malignant  pem- 
phigus have  apparently  got  well  under  quinine.  Under 
some  circumstances,  in  the  chronic  form,  the  disease  may 


PEMPHIGUS  63 

subside  in  a  few  months,  or  again  the  successive  formation 
of  bulk*  may  continue  for  life.  On  the  other  hand,  relapses 
are  not  uncommon.  In  some  cases  death  results  more  or 
less  speedily,  especially  in  debilitated  or  elderly  persons, 
from  the  exhaustion  incident  to  the  process,  or  else  from 
some  intercurrent  disease.  The  prognosis  in  pemphigus 
foliaceus  is  invariably  hopeless. 

Treatment. — In  acute  pemphigus,  rest  in  bed,  nourishing 
food,  stimulants,  quinine  for  the  fever,  and  appropriate 
tonics  are  demanded,  according  to  the  necessities  of  the 
case. 

In  chronic  pemphigus  it  is  of  vital  importance  to  keep 
up  the  strength  of  the  patient  and  to  secure  sleep.  Arsenic 
is  regarded  as  almost  a  specific  by  some  authorities,  but 
this  is  by  no  means  the  unanimous  opinion.  Unquestion- 
ably in  many  instances  it  seems  to  control  the  disease, 
but  relapse  too  often  occurs  when  the  drug  is  stopped.  It 
is  seemingly  more  efficacious  in  children  than  in  adults, 
but  we  do  not  believe  that  the  bullous  eruption  in  the  former 
represents  a  true  pemphigus. 

It  is  best  to  give  arsenic  in  solution,  and  to  begin  with 
small  doses  gradually  increased  to  the  point  of  toleration. 
The  tincture  of  belladonna  given  in  the  same  way  is  a 
remedy  of  value  in  some  cases,  and  it  has  succeeded  in  our 
hands  when  other  agents  had  failed.  Crocker  believes 
salicin  to  be  a  useful  remedy  in  pemphigus,  and  we  have 
come  to  the  same  conclusion  from  our  own  experience  with 
it.  It  should  be  given  in  doses  of  from  10  to  30  gr.,  three 
times  a  day,  preferably  in  wafers. 

The  deodorized  tincture  of  opium  is  also  of  much  ser- 
vice, given  either  alone  or  in  combination  with  arsenic. 
Opium  has  been  especially  recommended  by  Hutchinson  in 
pemphigus  vegetans.  Among  other  remedies  that  have  been 
employed  may  be  mentioned  strychnine  (hypodermically), 
pilocarpine,  chlorate  of  potassium,  quinine,  and  antipyrine. 
The  local  treatment  consists  in  measures  for  the  relief  of 
pain,  the  healing  of  denuded  areas,  and  the  proper  cleaning 
and  disinfection  of  the  skin.  The  blebs  may  be  punctured 


64  INFLAMMATIONS 

to  relieve  the  feeling  of  tension,  but  the  pricks  should  be 
made  at  their  bases,  so  that  the  roofs  may  remain  intact, 
in  this  way  serving  as  a  protective  covering  to  the  raw  sur- 
faces beneath.  Simple  powders  may  be  dusted  on  in 
mild  cases,  and  the  parts  protected  with  a  layer  of  absorb- 
ent cotton.  Great  care  should  be  taken  to  prevent  the 
rupture  of  blisters,  but  when  such  an  accident  has  taken 
place  the  raw  places  may  be  dressed  with  simple  zinc 
salve  or  boric  acid  ointment.  When  extensive  surfaces  are 
involved,  croton  oil,  to  which  has  been  added  a  small 
amount  of  creosote,  gives  the  greatest  comfort.  Crocker's 
calamine  liniment  somewhat  modified  is  also  agreeable  and 
soothing. 

]$—  Zinci  oxidi    .  3j 

Pulv.  calaminae  prsep 3j 

Ol.  amygdalae  dulcis. 

Liquoris  calcis aa  5j 

Lanolini 3jss — M. 

Various  kinds  of  medicated  baths  have  been  advised  in 
pemphigus,  such  as  the  bran,  starch,  gelatin,  or  alkaline 
bath,  or  those  containing  permanganate  of  potassium, 
sulphuret  of  calcium,  corrosive  sublimate,  decoction  of 
oak  bark;  and,  especially  for  pemphigus  foliaceus  and 
pruriginosus,  the  tar  bath.  (See  Baths.)  The  continuous 
warm  bath  of  Hebra  may  be  tried  in  hospital  practice,  but 
it  is  hardly  practicable  among  private  patients. 

The  lesions  occurring  in  the  mouth  and  throat  should 
receive  the  requisite  attention.  Spiegler  recommends 
rinsing  the  mouth  with  a  decoction  of  coca  leaves,  the 
coca  acting  both  as  an  astringent  and  a  local  anesthetic. 
Excoriated  places  may  be  gently  touched  with  iodine 
or  a  weak  solution  (5  to  10  per  cent.)  of  nitrate  of  silver. 
Papillary  growths  occurring  in  the  axillae  and  groins  in 
pemphigus  vegetans  may  be  dusted  witli  xeroform  or  some 
similar  powder,  and  it  is  possible  that  great  benefit  might 
be  obtained  from  exposure  to  ar-rays.1 

1  The  local  measures  recommended  for  pemphigus  vulgaris  may 
be  also  employed  for  the  foliaceous  form  of  the  disease. 


IMPETIGO  HERPETIFORMIS  65 

ADDITIONAL  PRESCRIPTIONS. 

I£ — Zinci  oxidi 5j 

Talci  Venetian! 3j 

Vaselini 3ij — M. 

S. — External  use.  Spiegler. 

1$ — Sulphuris  prsecipitati, 
Zinci  oxidi, 

Amyli aa    Sijss 

Vaselini  flavi Svijss — M. 

S. — External  use.    To  hasten  regeneration  of  the  epidermis. 

Jarisch. 

J$ — Acid,  borac.  sol.  in  glycerin gr.  xv-xxx 

Adi  pis  benzoati 3xxv 

S. — External  use.  Spiegler. 

1$ — Cretse  prsoparatae, 

Zinci  oxidi, 

Olei  lini, 

Liq.  calcis aa    3ijss— M. 

S. — Apply  as  a  liniment.  Unna. 


IMPETIGO  HERPETIFORMIS. 

Description. — Impetigo  herpetiformis  is  a  very  rare  dis- 
ease occurring  mostly  in  pregnant  women,  although  a  few 
cases  have  been  observed  in  males.  The  eruption  usually 
develops  first  on  the  inner  side  of  the  thighs  and  about  the 
groins,  navel,  breasts,  and  axillae. 

The  local  manifestations  consist  of  superficial  miliary 
pustules,  which  may  be  discrete,  but  are  usually  closely  set. 
They  have  a  tendency  to  form  circular  groups.  The  con- 
tents of  the  pustules,  at  first  opaque,  later  become  greenish 
yellow,  and  dry  into  dirty,  brown  crusts.  While  the  central 
pustules  are  undergoing  this  evolution,  new  lesions  appear 
around  the  border  of  the  patch,  and  by  coalesence  large 
areas  become  involved.  If  the  crusts  be  removed,  the  skin 
is  seen  to  be  red  and  covered  with  a  new  epidermis,  moist 
as  in  eczema,  with  a  smooth,  infiltrated  surface,  or  present- 
ing papillary  elevations.  The  mucous  membranes  of  the 
tongue,  oral  cavity,  and  esophagus  may  be  involved.  With 
5 


66  INFLAMMATIONS 

a  few  exceptions  the  disease  has  proved  fatal  in  all  the 
recorded  cases. 

Treatment. — The  treatment,  general  and  local,  should  be 
conducted  on  general  principles,  that  is,  quinine  for  the 
fever,  together  with  suitable  food,  stimulants,  etc.,  while 
the  external  application  should  consist  of  soothing  and 
antiseptic  salves,  e.g.,  10  per  cent,  xeroform  ointment, 
and  the  occasional  warm  bath,  alkaline  or  carbolated. 
On  theoretical  grounds  the  avrays  may  be  recommended. 
Premature  delivery  should  be  advised  in  cases  occurring 
in  pregnant  women. 


DERMATITIS  HERPETIFORMIS. 

Description. — Dermatitis  herpetiformis,  or  Duhring's 
disease,  is  an  inflammatory  affection  of  an  herpetic  char- 
acter, the  various  lesions  showing  a  tendency  to  group. 
It  is  a  protean  malady,  and  manifests  itself  in  various 
elementary  forms,  such  as  erythema,  vesicles,  papules, 
pustules,  and  blebs.  Any  one  of  these  forms  may  occur 
alone,  or  two  or  more  may  coexist,  or  even  may  merge  the 
one  into  the  other,  thus  constituting  a  mixed  eruption. 
Multiformity  of  lesion  is,  therefore,  a  prominent  char- 
acteristic. 

The  commonest  expression  is  the  mixed  eruption  with 
the  vesicular  type  predominating.  In  some  cases,  espe- 
cially those  of  severe  type,  certain  symptoms  of  invasion 
occur,  such  as  malaise,  more  or  less  fever  and  marked 
pruritus,  or  these  prodromal  symptoms  may  be  absent 
altogether.  Again,  in  some  instances  during  the  first  few 
days  of  an  outbreak,  particularly  when  of  the  pustular  or 
bullous  type,  grave  constitutional  symptoms  may  be  pres- 
ent, but  violent  systemic  reaction  is  unusual. 

Itching  and  burning  are  the  most  marked  subjective 
symptoms,  while  crusting,  infiltration,  and  pigmentation 
are  prominent  secondary  features.  The  course  of  the 
disease  is  variable,  but  usually  chronic,  relapsing,  and  of 


DERMATITIS  HERPETIFORMIS  07 

indefinite  duration.  The  mucous  membranes  may  also  be 
involved. 

Etiology. — The  etiology  of  the  disease  is  obscure,  although 
in  a  general  way  the  disorder  may  be  regarded  as  a  neurosis 
of  the  skin ;  that  is  to  say,  nervous  shock  or  nervous  exhaus- 
tion are  factors  of  much  importance  in  the  clinical  histories 
of  many  of  the  cases;  but  it  also  must  be  admitted  that  in 
a  considerable  number  of  instances  other  predisposing  or 
exciting  causes  are  seemingly  responsible,  e.  g.,  glycosuria 
albuminuria,  vaccination,  etc.  Sometimes  the  general 
health  is  apparently  unimpaired.  Engman  has  called  atten- 
tion to  the  occasional  incidence  of  indicanuria,  an  obser- 
vation which  we  have  several  times  confirmed. 

Prognosis. — The  prognosis  is  always  grave,  although 
temporary  relief  from  the  eruption  may  be  obtained,  and 
the  patient  made  fairly  comfortable  by  appropriate  treat- 
ment. The  outlook  is  more  favorable  for  permanent  cure 
in  children. 

Treatment. — The  treatment,  so  far  as  the  permanent 
cure  of  the  disease  is  concerned,  is  far  from  encouraging. 
Much,  however,  can  be  accomplished  in  the  way  of  miti- 
gating the  patient's  present  sufferings,  in  shortening  the 
attacks  and  lengthening  the  intervals  between  them.  In 
all  cases  the  patient's  general  condition  should  be  diligently 
enquired  into,  and  as  far  as  possible  any  departure  from 
health  should  be  remedied.  The  diet  should  be  plain,  yet 
generous,  and  tea,  coffee,  alcohol,  and  tobacco  should,  as 
a  rule,  be  forbidden.  A  pure  milk  diet  is,  in  rare  cases, 
apparently  helpful,  but  in  our  experience  the  majority  of 
patients  experience  no  benefit  from  it.  Intestinal  antiseptics 
are  often  of  value.  The  following  formula  makes  a  good 
combination.1 

1$ — Sodii  sulphocarbolatis gr.  y 

Potassii  permanganatis gr.  j 

Beta-naphthol gr.  j — M 

Tliis  pill  should  be  coated  with  shellac. 

S. — One  after  meals  and  at  night. 

1  This  is  Starr's  modification  of  Rachford's  pill,  which  is  a  1  gr. 
snlol-n  Kited  pill  of  potassium  permanganate. 


68  INFLAMMATIONS 

There  is  no  specific  internal  treatment,  but  arsenic  has 
undoubtedly  much  influence  over  the  eruption,  both  in 
cutting  short  the  attacks  and  prolonging  the  periods  of 
freedom  from  the  disease. 

It  must  be  given  in  comparatively  large  doses  or  even 
pushed  to  the  point  of  tolerance.  The  more  the  disease 
approaches  the  bullous  type,  the  more  beneficial  is  the 
arsenic,  and  we  may  add  that  children  get  more  good  from 
it  than  grown  people. 

Sometimes  the  Asiatic  pill  seems  to  be  more  efficacious 
than  Fowler's  solution.  It  must  be  confessed,  however, 
that  very  often  arsenic  in  any  form  proves  useless,  or  may 
even  prove  distinctly  harmful. 

Belladonna  in  the  form  of  the  tincture,  given  as  in  pem- 
phigus, may  be  tried  in  refractory  cases,  but  it  is  not  nearly 
so  efficient  as  the  first-named  drug;  yet  we  have  seen  it 
succeed  where  arsenic  has  failed.  Among  other  general 
remedies  may  be  mentioned  quinine,  salicin,  and  ergotin. 
Sulphur  long  continued,  especially  in  the  form  of  Garrod's 
compound  sulphur  lozenges,  one  three  times  a  day,  is 
worthy  of  trial.  Adrenalin  solution  has  been  given  hypo- 
dermically  with  asserted  benefit.  Cannabis  indica,  10  to 
20  drops  of  the  tincture  three  times  a  day,  and  antipyrine 
at  night  in  one  large  dose,  has  afforded  relief  in  some  cases. 
Phenacetin  and  salol,  5  gr.  each,  several  times  a  day, 
are  occasionally  useful.  Indicanuria  should  be  sought  for, 
and,  when  found,  the  indications  will  be  for  the  restriction 
of  proteid  food  and  the  use  of  saline  laxatives.  For  local 
treatment  Duhring  regards  sulphur  in  the  strength  of  2 
drachms  to  1  oz.  of  excipient  as  the  most  valuable  of  all 
external  applications  in  dermatitis  herpetiformis,  except  in 
the  erythematous  form.  It  should  be  thoroughly  rubbed 
into  the  affected  parts.  There  is  no  doubt  of  its  efhV;i<-y, 
particularly  in  allaying  the  tormenting  pruritus. 

Elliott  advises  ichthyol  in  the  following  preparation : 

IJ — Ammonii  ichthyolatis 3vjss-xiij 

Olei  amygdalae  dulcis, 

Liquoris  calcis aa,     Sviij — M. 


DERMATITIS  HERPETIFORMIS  69 

This  may  be  rubbed  in  several  times  a  day  and  allowed 
to  remain  on  the  surface;  or  lint  may  be  soaked  in  the 
lotion  and  kept  in  place  by  a  bandage. 

A  lotion  of  zinc  sulphate,  1  oz.  to  1  pt.  of  water,  a  prep- 
aration of  great  value  in  dermatitis  venenata,  is  sometimes 
useful  in  this  disease  also.  The  following  combination  of 
menthol  and  carbolic  acid  affords  relief  from  the  itching: 

1^ — Mentholis 3ij 

Alcoholis q.  s. 

Acidi  carbolic! 3ss 

Lotion,  zinci  oxidi  co q.  s.  ad  5vj 

S. — Mop  on  gently  with  soft  cloth. 

As  an  antipruritic  remedy,  Winfield  recommends  liquor 
picis  alkalinus  in  the  strength  of  1  drachm  to  8  or  12  oz. 
of  water,  or  the  liquor  carbonis  detergens  1  drachm  to  4  or 
6  oz.  of  water. 

Soothing  ointments  are  sometimes  more  agreeable  than 
lotions,  especially  for  excoriated  places.  The  modified 
diachylon  ointment,  spread  on  cloth,  is  suitable  for  this 
purpose.  In  the  vesicular  and  bullous  types  Lassar's 
paste  is  a  good  application,  and  we  have  had  much  satis- 
faction from  Pick's  linimentum  exsiccans  (q.  v.},  to  which 
has  been  added  10  per  cent,  of  zinc  oxide  and  1  per  cent, 
carbolic  acid. 

General  galvanism  and  static  insulation  have  been 
suggested. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Sulphuris  praccipitati, 
Ichthyolis 

Vaselini aa     Sijss 

Gelanthi Svss 

S. — Apply  externally  in  the  erythematous  type. 

Leistikow. 

I$— Thioli 5ijss 

Aquse  destillatse §ij — M. 

S. — Paint  upon  eruption  with  camel's-hair  brush;  later  wash  off 
with'pure  water. 

Schwimmer. 


70  INFLAMMATIONS 

1$ — Quininae  hydrochloratis gr.  xlv 

Ext.  belladonnas gr.  xxijss 

Ext.  nucis  vomicse gr.  xv 

Ergotini gr.  Ixxv 

Ft.  pil.  No.  100. 

S. — Take  two  pills  twice  daily  in  the  intervals  between  attacks. 

Leistikow. 


HYDRO  A  VACCINIFORME  seu  FESTIVALS. 

Description. — This  rare  disorder  makes  its  appearance 
in  the  first  years  of  life,  and  particularly  afflicts  male 
children.  The  outbreak  usually  occurs  in  summer,  and 
may  recur  for  a  number  of  years,  generally  ceasing  at  the 
age  of  puberty,  if  not  earlier.  Sudden  violent  changes  of 
temperature,  in  either  direction,  or  artificial  heat,  may 
provoke  an  attack. 

As  a  rule  the  eruption  is  preceded  by  some  slight  sys- 
temic disturbance,  and,  perhaps,  a  burning  sensation  may 
be  experienced  at  the  future  site  of  the  eruption. 

It  begins  either  in  the  form  of  vesicles,  or  as  small,  red 
elevations  which  speedily  develop  into  clear  vesicles,  or 
bullse,  that  often  coalesce.  Many  of  the  vesicles  become 
umbilicated  and  are  surrounded  by  a  red  areola.  The 
centre  assumes  a  dark-blue  or  black  shade,  owing  to 
hemorrhage  into  the  corium  with  subsequent  necrosis. 
Soon  some  of  the  lesions  become  purulent,  and  in  three  or 
four  days  the  necrotic  centre  is  converted  into  a  thick, 
black,  firmly  adherent  crust,  which,  when  it  comes  away, 
leaves  a  permanent  variola-like  cicatrix.  Usually  there  is 
slight,  if  any,  itching.  Such  attacks  generally  last  two  or 
three  weeks,  or  perhaps  longer,  owing  to  the  appearance 
of  new  lesions.  The  eruption  is  usually  situated  on  parts 
exposed  to  the  sun's  rays,  viz.,  the  bridge  of  the  nose, 
cheeks,  and  ears,  and  sometimes,  when  uncovered,  the  legs. 

Treatment. — The  treatment  is  not  promising.  It  has 
been  recommended  to  use  veils  of  red  or  tumeric  colors  to 
neutralize  the  chemical  rays,  or  to  smear  the  parts  with  a 
brown  pigment.  During  an  actual  attack  the  blisters  may 


ECZEMA  71 

be  opened  and  the  surface  dressed  with  a  modified  dia- 
chylon salve  containing  1  or  2  scruples  of  xeroform  or 
aristol  to  1  oz. 


EPIDERMOLYSIS. 

This  is  a  rare  affection  and  is  characterized  by  the 
appearance  of  blebs  that  occur  on  the  skin  in  response  to 
some  local  irritation,  even  of  the  slightest  kind.  This 
tendency  first  manifests  itself  in  infancy  and  would  seem 
to  be  permanent,  although  it  is  said  to  decrease  toward 
middle  life.  It  is  in  all  probability  hereditary  and  may 
affect  several  members  of  a  family.  It  is  most  apt  to  occur 
in  summer,  and  is  often  accompanied  by  hyperidrosis. 

The  lesions  may,  or  may  not,  be  preceded  by  itching  and 
redness;  there  is,  however,  no  disturbance  of  the  general 
health.  The  blebs  are  of  various  sizes  and  may  be  clear, 
purulent,  or  hemorrhagic,  and  disappear  without  scar 
formation.  Pigmentation  has  been  noted  in  a  few  cases. 
When  the  finger-ends  are  involved,  nail  loss  or  deformity 
may  ensue.  Any  portion  of  the  body  may  be  affected,  but 
especially  the  hands  and  about  joints,  these  regions  being 
particularly  subject  to  irritation;  also  localities  where  there 
is  friction  from  clothing,  as  the  neck,  wrists,  etc. 

Treatment. — Little  can  be  expected  from  any  treatment. 
Internally,  tonic  remedies,  e.g.,  arsenic,  ergotin,  quinine 
belladonna,  etc.,  have  been  recommended  and  may  be 
given  a  trial.  Locally,  fatty  ointments,  or  baths,  followed 
by  dusting  powders,  may  be  ordered;  and  when  there  is 
coexisting  hyperidrosis,  sprinkling  with  tannoform  has 
been  proposed. 

ECZEMA. 

Description. — Eczema  is  an  acute,  subacute,  or  chronic 
inflammatory  disease  of  the  skin,  characterized  by  multi- 
formity of  lesions  and  the  presence  in  varying  degrees  of 


72  INFLAMMATIONS 

itching,  infiltration,  and  discharge.  Crusting,  scaling,  fis- 
suring,  and  sometimes  hypertrophic  changes,  are  to  be 
regarded  as  secondary  results. 

It  may  be  broadly  stated  that  eczema  always  begins  as  a 
congestion  of  the  skin,  and  always  ends  in  desquamation ; 
but  between  these  two  conditions  there  may  intervene 
papulation,  vesiculation,  pustulation  and  various  secondary 
alterations.  This  disease  is  particularly  characterized  by 
its  exudation  or  discharge,  in  which  it  bears  a  close  like- 
ness to  the  catarrhal  inflammations  of  mucous  membranes. 
This  exudation  possesses  the  peculiar  power  of  stiffening 
and  staining  linen.  It  is  by  no  means  true,  however,  that 
eczema  is  invariably  a  moist  disease,  for  certain  cases  never 
develop  this  feature,  at  least  spontaneously,  but  even  a  dry, 
papular  or  erythematous  eczema  may  be  made  to  exude 
this  characteristic  catarrhal  discharge  by  the  influence  of 
slight  external  irritation.  In  a  general  way  eczema  may 
be  said  to  develop  symmetrically;  thus,  if  it  is  found  on  one 
hand  it  usually  occupies  a  corresponding  situation  on  the 
other,  and  so  on  the  legs;  but  it  is  not  invariably  and  con- 
stantly bilateral  like  psoriasis,  for  frequently  enough  it  may 
be  seen  in  large  or  small  patches  on  indifferent  parts  of  the 
body.  The  disease  is  rarely  universal  except  in  very 
elderly  or  unusually  weakly  subjects,  and  the  general 
health  suffers  but  little,  notwithstanding  the  often  free 
discharge  and  the  nervous  erethism  induced  by  scratching 
and  loss  of  sleep.  Eczema  is  more  frequently  seen  in  its 
chronic  form.  As  in  catarrhal  inflammations  in  general, 
the  tendency  to  relapse  is  one  of  its  pronounced  character- 
istics. 

Symptoms. — The  principal  subjective  symptoms  present 
are  itching,  and  more  or  less  soreness  and  pain  that  follow 
violent  scratching  or  nibbing  of  the  affected  parts.  The 
degree  of  pruritus  will  vary  according  to  the  age  of  the 
patient,  the  extent  and  location  of  the  disease,  and  the 
character  of  the  -predominant  lesion.  Papular  eczema  is, 
perhaps,  the  most  and  pustular  eczema  the  least  annoying 
in  this  regard.  An  acute  attack  of  the  diseasermay  be 


ECZEMA  73 

ushered  in  with  some  slight  elevation  of  temperature,  but 
often  no  such  disturbance  is  apparent;  the  local  disorder, 
however,  will  present  the  ordinary  symptoms  of  cutaneous 
inflammation,  viz.,  burning,  tingling  or  itching,  to  be  fol- 
lowed by  some  one  or  several  of  the  elementary  forms  of 
the  disease.  On  the  other  hand,  the  disease  may,  and  often 
does,  begin  more  insidiously,  and  is  subacute  from  the 
start.  In  this  latter  condition  the  itching  and  thickening 
of  the  skin  is  moderate  in  degree,  but  at  any  time  a  more 
acute  process  may  supervene,  or,  the  disease  continuing, 
the  infiltration  and  pruritus  may  become  more  marked, 
other  secondary  changes  may  occur,  and  the  eczema  lapse 
into  a  chronic  stage  that  may  endure  for  years. 

As  already  stated,  eczema  is  characterized  by  a  poly- 
morphous eruption  consisting  of  erythema,  papules, 
vesicles,  and  pustules,  and,  moreover,  any  one  of  these 
lesions  may  be  present  singly,  or  more  or  less  in  combina- 
tion. Still  at  times  one  or  another  of  these  elementary 
forms  may  so  predominate  as  to  establish  the  anatomical 
general  type  of  the  eruption — for  a  season  at  least.  These 
may  be  briefly  described  as  follows : 

Erythematous  eczema  makes  its  appearance  in  the  shape 
of  ill-defined,  red,  and  somewhat  infiltrated  patches,  accom- 
panied by  burning,  tingling,  and  itching.  The  shades  of 
color  will  vary  from  a  light-red  to  a  reddish-purple  or  even 
a  tawny  hue.  It  is  usually  confined  to  limited  regions,  such 
as  the  legs,  backs  of  the  hands,  inner  surfaces  of  the  thighs, 
under  the  breasts,  and  more  especially  the  face.  In  the  lax 
tissues  of  the  last-named  region  great  swelling  of  the  skin 
with  closure  of  the  eyes  often  occurs,  leading  to  an  errone- 
ous diagnosis  of  erysipelas. 

Papular  eczema  manifests  itself  in  the  form  of  small,  red, 
acuminated  papules  that  are  either  closely  set  on  an  in- 
flamed base,  or  else  irregularly  scattered  over  the  surface. 
If  this  disorder  become  chronic,  the  lesions  lose  their 
separate  identity  and  run  together  to  form  leathery,  scaly 
patches;  or  if  the  surface  have  been  greatly  irritated,  an 
eczema  rubrum  results.  Itching  is  a  marked  feature.  The 


74  INFLAMMATIONS 

favorite  sites  for  this  form  of  disease  are  the  face  and  the 
extensor  surfaces.  Relapse  is  common. 

Vesicular  eczema  usually  runs  an  acute  course,  the  lesions 
consisting  of  pin-point  to  pin-head  sized  elevations  of  the 
epidermis,  containing  clear  or,  after  awhile,  opaque  fluid. 
The  exudative  or  weeping  stage  will  often  persist  after  the 
rupture  of  the  vesicles,  which  event  happens  quickly  as  a 
rule,  either  from  the  development  of  new  lesions  or  as  a 
general  oozing  from  the  raw  and  denuded  surface.  On 
the  other  hand,  the  exudation  may  dry  into  yellowish, 
gummy,  easily  detachable  crusts,  which,  upon  removal, 
show  a  moist  surface  underneath. 

Under  proper  treatment  the  vesicles  may  dry  up  without 
rupture,  the  integument  being  left  red,  scaly,  and  thickened. 

The  sites  of  predilection  of  this  form  of  the  disease  are 
the  flexor  surfaces  of  the  limbs,  the  hands,  and  the  sides  of 
the  fingers,  although  it  often  attacks  the  dorsal  and  the 
palmar  surfaces.  Vesicular  eczema  is  also  comparatively 
common  on  the  faces  and  scalps  of  children. 

Pustular  eczema  may  originate  directly  in  the  form  of 
pustules,  or  the  pustular  lesions  may  develop  from  vesicles, 
or  follow  in  the  wake  of  other  primary  types.  It  is  to  be 
presumed,  however,  that  pus  cocci  and  a  suitable  soil  are 
the  main  factors.  It  is  most  frequently  found  about  the 
heads  and  faces  of  children,  and  also  is  seen  in  weakly 
adults.  Itching  is  not  marked.  In  the  shape  of  a  secondary 
folliculitis  the  eruption  is  often  seen  on  the  bearded  face,  in 
the  axillary  and  pubic  regions,  and  on  other  hairy  parts. 

While  any  one  of  the  types  of  the  disease  briefly  men- 
tioned above  may  run  its  course  as  such,  or  may  be  more 
or  less  commingled  with  other  primary  forms,  it  is  never- 
theless true  that  eczema,  as  seen  in  practice,  has  usually 
undergone  certain  secondary  changes  as  follows : 

Eczema  Rubrum. — Any  .of  the  primary  forms  of  the  dis- 
ease may  be  followed  by  this  condition,  although  it  is  more 
common  after  the  vesicular  and  pustular  types.  As  a  result 
of  the  exposure  of  the  rete  from  the  shedding  of  the  upper 
epithelial  layers,  the  surface  is  red,  and  gives  issue  to  a 


ECZEMA  75 

clear  or  turbid,  sticky  fluid,  that  is  apt  to  dry  into  yellow, 
flaky  crusts;  or  the  skin  has  a  bright-red,  smooth,  and 
somewhat  glazed  appearance,  sometimes  showing  small 
points  of  ulceration  corresponding  to  ruptured  vesicles  or 
glandular  apertures.  When  decided  thickening  is  present, 
cracks  and  fissures  may  be  observed,  from  which  issues  a 
serous  or  sanious  discharge.  Itching  is  marked,  although 
generally  paroxysmal  in  character.  Eczema  rubrum  cor- 
responds most  nearly  with  the  popular  idea  of  salt  rheum. 
It  is  most  typically  seen  on  the  legs  of  middle-aged  people, 
in  the  flexures  of  joints,  and  on  the  faces  of  children. 

Eczema  Squamosum. — Squamous,  or  scaly  eczema  may 
follow  any  of  the  elementary  forms  of  the  disease,  and  is 
usually  indicative  of  a  decline  in  the  activity  of  the  inflam- 
matory process.  It  occurs  mostly  in  patches  of  variable 
size,  that  are  red,  infiltrated  and  covered  with  large  or 
small  scales.  It  is  often  encountered  on  the  scalp,  on  the 
back  of  the  neck,  and  sometimes  widely  disseminated  over 
the  body.  In  many  instances,  undoubtedly,  squamous 
eczema  corresponds  to  what  today  is  called  seborrheic 
eczema. 

Other  secondary  conditions  met  with  in  the  course  of 
eczema  have  received  various  names  that  more  or  less 
accurately  describe  the  objective  conditions  present.  Thus, 
when  the  infiltration  is  excessive  the  affection  is  called 
eczema  sclerosum ;  when  there  is  marked  hypertrophy  of  the 
papilla?,  and  the  skin  presents  a  diffuse  warty  aspect,  it  is 
characterized  as  eczema  verrucosum ;  if  the  deeply  infiltrated 
skin  is  cracked  and  fissured,  the  state  is  termed  eczema 
fissum,  and  finally  eczema  occurring  in  children  is  spoken 
of  as  eczema  infantile. 

Ulcerative  lesions  are  not  common  in  eczema,  but  they 
may  sometimes  be  observed  in  unhealthy  children  suffering 
from  the  disease.  Boils  and  abscesses,  due  to  pus  infection, 
may  also  be  noted  in  similar  conditions,  and  are  kept  up 
and  disseminated  by  scratching. 

Etiology. — In  order  intelligently  to  treat  eczema,  it  is  of 
the  utmost  importance  to  appreciate  the  main  facts  in  the 
etiology  of  the  disease. 


76  INFLAMMATIONS 

Eczema  is  the  most  common  of  all  skin  affections.  No 
age  or  social  condition  is  exempt  from  its  attacks,  and  both 
sexes  suffer  equally.  Eczema  is  not  hereditary  in  the  sense 
that  syphilis  is,  but  eczematous  parents  may  have  eczema- 
tous  offspring.  In  such  instances  the  predisposed  and  sus- 
ceptible skin  is  inherited,  rather  than  a  so-called  diathetic 
condition. 

The  disease  is  not  contagious  even  in  the  assumed  para- 
sitic variety,  but  an  irritating  discharge  coming  in  contact 
with  the  susceptible  skin  of  another  person  may  provoke  it. 

A  purely  local  eczema  may  reflexly  determine  an  attack 
at  some  distant  point  and  even  induce  a  general  outbreak. 

Eczema  is  not  a  diathetic  condition  dependent  upon  any 
single  state  of  the  general  system,  whether  denominated  as 
gouty,  or  dartrous,  or  rheumatic,  although  any  one  of  these 
conditions  may  act  as  a  predisposing  cause;  but,  stated 
briefly,  it  may  be  reasonably  presumed  that  the  eczematous 
subject  presents  a  vulnerable  cutaneous  system,  and  that 
under  certain  conditions  the  disease  may  be  evoked  by 
any  irritant,  internal  or  external,  capable  of  arousing  this 
susceptibility. 

Among  the  commonly  accepted  internal  causes  of  eczema 
may  be  mentioned  various  derangements  of  nervous 
function,  e.  g.,  mental  shock,  extreme  mental  worry,  and 
nervous  exhaustion.  Reflex  irritation  from  uterine  dis- 
orders, the  influence  of  pregnancy,  and  of  the  climacteric 
period,  have  been  regarded  as  causative  factors.  Unna 
recognizes  a  special  nervous  eczema  of  dentition,  and  G. 
H.  Fox  states  that  an  adherent  prepuce  is  often  responsible 
for  the  disease  in  children. 

Erythematous  eczema  of  the  face  due  to  chronic  gastric 
derangements  is  a  notoriously  frequent  and  rebellious  form 
of  the  affection. 

Certain  articles  of  food  and  drink  are  capable  of  inducing 
eczema,  inasmuch  as  they  produce  derangements  of  the 
stomach  and  bowels.  Gout,  lithemia,  and  other  general 
disorders  perhaps  act  in  the  same  way. 

Eczema  occurring  in  middle  life  is  often  associated  with 


ECZEMA  77 

diabetes,  and  less  frequently  with  albuminuria.  It  is 
thought  by  some  authorities  that  malaria  has  a  direct 
etiological  connection  with  eczema;  and  asthma  is  often 
seen  in  alternation  with  attacks  of  the  former  affection. 
We  do  not  doubt  at  all  that  mucous  membranes  suffer 
from  the  eczematous  process. 

The  poorly  nourished  and  strumous,  especially  among 
children,  are  peculiarly  prone  to  eczema,  often  of  the  pus- 
tular type,  presenting  enlarged  glands  ciliary  blepharitis, 
and  otorrhea  as  complications. 

Eczema  is  frequently  seen  after  the  eruptive  fevers, 
especially  measles,  and  postvaccinal  eczema  is  occasionally 
encountered.  As  in  grown  persons,  dietetic  errors,  with 
resulting  gastro-intestinal  derangements  and  the  pro- 
duction of  toxins,  are  responsible  for  many  eczemas  in 
infants. 

We  have  seen  rebellious  eczemas  in  children  yield  readily 
to  treatment  after  the  removal  of  adenoid  growths. 

Any  form  of  external  irritant  may  set  up  an  eczema, 
e.  g.,  chemicals,  sugar,  flour,  lime,  soap,  hard  water,  rough 
underclothing.  Thus,  we  find  the  disease  in  chemists, 
physicians,  bricklayers,  washerwomen,  bar-tenders,  and 
grocers.  A  varicose  condition  of  the  veins,  often  associated 
with  flatfoot,  is  a  common  exciting  cause. 

Cold  and  excessive  heat,  especially  when  the  latter 
causes  free  sweating,  may  be  added  to  this  list  of  excitants ; 
also  seborrhea,  and  the  irritation  produced  primarily  or 
secondarily  by  microorganisms. 

Diagnosis. — If  the  chief  features  of  eczema,  as  given 
above,  be  borne  in  mind,  the  difficulties  of  diagnosis  are  as 
a  rule  not  very  great;  but  the  following  diseases  may, 
under  certain  circumstances,  have  a  sufficiently  close 
resemblance  to  it  to  warrant  a  degree  of  circumspection  in 
coming  to  a  conclusion,  especially  in  ill-defined  examples 
of  the  respective  affections.  These  disorders  are:  Scabies, 
lichen  planus,  erysipelas,  dermatitis  herpetiformis,  pso- 
riasis, herpes,  urticaria,  pemphigus,  acne  rosacea,  and 
certain  forms  of  syphilis. 


78  INFLAMMATIONS 

Treatment. — To  the  physician  acquainted  with  the  mani- 
fold conditions,  general  and  local,  that  may  directly  or 
indirectly  be  concerned  in  the  production  of  the  inflam- 
mation of  the  skin  that  is  called  eczema,  it  is  clear  that  a 
successful  treatment  is  based  upon  something  more  than  a 
hasty  and  unconsidered  prescription.  On  the  contrary, 
the  patient's  constitutional  peculiarities,  his  habits,  occu- 
pation, and  present  physical  condition  should  be  carefully 
enquired  into  before  prescribing  internal  remedies,  if, 
indeed,  such  medication  is  needed  at  all,  and  the  location, 
type,  and  stage  of  the  eruption  should  be  minutely  noted 
before  ordering  local  applications. 

The  old  question  whether  it  is  safe  to  cure  an  eczema 
rapidly,  especially  in  children  and  old  people,  has  again 
been  revived  in  late  years  by  a  few  writers.  We  think, 
however,  that  the  vast  majority  of  practitioners  are  fully 
agreed  that  there  is  no  danger  in  curing  an  eczema  as 
quickly  as  possible,  as  an  abundant  experience  has  shown 
that  not  only  no  harm  follows,  but  that  the  patient's  well- 
being  is  greatly  promoted  by  removing  a  constant  source 
of  general  and  local  irritation. 

The  eczematous  patient  should  endeavor  to  avoid,  as  far 
as  possible,  all  sources  of  external  or  internal  irritation. 
Among  the  more  usual  external  irritating  agencies  may  be 
mentioned  various  chemical  substances:  lime,  sugar,  flour, 
dust,  the  pressure  of  ill-fitting  or  rough  garments,  and  hard 
water  and  bad  soap.  Persons  who  perspire  freely  in  hot 
weather,  or  as  a  result  of  too  vigorous  exercise,  should 
always  keep  the  skin  well  powdered.  Alcoholic  drinks 
and  overindulgence  in  tea,  coffee,  and  tobacco  should  be 
avoided,  as  also  such  fermentable  food  as  oatmeal,  pies, 
pastries,  etc.  We  are  quite  in  agreement  with  White  and 
Hutchinson  in  the  belief  that  eczema  is  often  provoked  or 
aggravated  by  acid  fruits. 

In  spite  of  Hall's1  very  interesting  investigations  in  the 
etiology  of  infantile  eczema,  in  which  he  rejects  the  idea  of 

1  Brit.  Jour.  Dermatology,  July-August,  1905. 


ECZEMA  79 

digestive  disturbance  as  a  factor  in  its  production,  offering 
instead  the  theory  of  external  irritation,  we  are  still  of 
the  opinion  that  a  suitable  dietary  is  of  great  importance. 
The  common  habit  of  stuffing  with  unwholesome  food 
should  be  forbidden,  and  the  medical  attendant  will  find 
it  wise  to  write  out  carefully  prepared  diet  lists  suitable  to 
the  age  of  the  patient.  If  the  child  is  being  suckled,  equal 
care  should  be  taken  with  the  mother's  diet,  and  she  should 
be  required  to  abstain  from  indigestible  and  overstimu- 
lating  food  and  drink;  and  if  the  nursing  mother  is  weak 
and  ill-nourished  she  should  be  put  on  appropriate  treat- 
ment. 

From  a  consideration  of  the  etiology  of  eczema  it  must 
be  obvious  that  we  possess  no  specifics  for  the  disease.  The 
internal  treatment  is  chiefly  symptomatic,  that  is,  we 
endeavor  as  far  as  possible  to  remove  presumable  existing 
causes  and  apparent  complications.  Very  often  indeed 
the  eczematous  patient  is  seemingly  in  the  enjoyment  of 
good  health,  and  the  exciting  cause  has  disappeared,  or  the 
disease  has  been  brought  into  existence  by  purely  local 
influences.  Under  such  circumstances,  it  is  not  incumbent 
upon  the  physician  to  invent  a  morbid  condition  in  order 
to  prescribe  for  it. 

The  habit  of  indiscriminate  purgation,  so  common 
formerly,  is  far  from  judicious,  but  a  mercurial  purge 
followed  by  a  saline  is  very  serviceable  in  acute  eczema, 
and  also,  repeated  occasionally,  in  the  more  chronic  attacks 
of  the  overfed  and  gouty.  Habitual  constipation  and  the 
various  forms  of  gastric  and  intestinal  dyspepsia  should 
receive  appropriate  treatment.  Startin's  well-known  mis- 
tura  ferri  acida  is  of  undoubted  value  in  the  constipation 
of  anemic  women,  especially  young  women  with  menstrual 
irregularities; 


— Magnesii  sulpliatis  . 
Ferri  sulpliatis    . 
Acidi  sulphuric!  diluti 
Sodii  chloridi 
Infus.  jrentiaiw 


Si 


IV 


.      .      .      3ss 

q.  s.  ad     5iv — M. 


S. — Tablespoon  ful  in  goblet  of  cold  water  one  hour  before  break- 
fast. 


80  INFLAMMATIONS 

From  one-half  to  one  teaspoonful  of  Carlsbad  salts,  or 
one-half  teaspoonful  of  bicarbonate  of  sodium,  in  a  large 
goblet  of  very  hot  water  one  hour  before  breakfast,  is  a 
good  routine  practice  in  persons  with  constipation  and 
impaired  digestion. 

The  syrup  of  rhubarb,  with  or  without  magnesia,  is  an 
excellent  aperient  for  children.  Small  doses  of  calomel, 
gr.  -^  to  ^  several  times  a  day,  or  in  nightly  doses  for  a 
considerable  time,  are  valuable  in  infantile  eczema.  The 
syrup  of  the  iodide  of  iron,  .or  Parrish's  chemical  food, 
should  be  given  to  delicate  children.  Cod-liver  oil  is  ser- 
viceable in  pustular  eczemas  at  any  age;  it  is  also  to  be 
prescribed  for  persons  showing  tuberculous  tendencies. 

We  have  found  the  following  formula  very  satisfactory: 

1$ — Ol.  morrhuae §iv 

Pancreatini  saccharati 3j 

Pulv.  acaciae .  q.  s. 

Glyceriti  hypophosphitis, 
Syr.  lactophosphatis, 

Aquse aa  5iv 

Olei  gaultherise gtt.  xxx — M. 

S. — Tablespoonful  three  times  a  day  for  adults. 

There  now  remain  to  be  considered,  briefly,  certain  drugs 
that  are  often  prescribed  for  their  presumed  direct  effect 
upon  the  eczema  itself,  or  as  combating  some  symptom  of 
the  affection.  Both  in  and  out  of  the  profession  arsenic 
has  long  enjoyed  a  reputation  as  in  some  sort  a  specific; 
yet,  as  a  matter  of  fact,  it  is  rarely  employed  by  derma- 
tologists. Arsenic  should  never  be  ordered  in  acute  eczema , 
and  its  efficacy  in  any  type  of  the  disease  is  more  than  doubt- 
ful. However,  if  there  are  no  particular  centra-indications 
to  its  use  it  may  be  tried  in  dry,  scaly  forms,  in  affections 
of  the  nails,  and  in  so-called  neurotic  eczema.  Arsenic 
should  always  be  given  directly  after  meals,  well  diluted, 
and  in  small  doses.  Fowler's  solution,  the  preferable 
form,  may  be  combined  with  wine  of  iron,  some  of  the 
peptonated  iron  preparations,  or  with  manganese. 


ECZEMA  81 


1$  —  Vini  ferri       .......... 

Syrupi  simplicis, 

Liq.  potasgii  arsenitis   ......   aa  5ij 

Aquae  destillatae       ........  5ij  —  M. 

S.  —  Teaspoonful  in  water  after  meals.  Wilson. 

Of  late  years  Mr.  Morris  has  reintroduced  the  use  of 
antimony  in  acute  eczema.  If  the  patient  is  in  good 
health,  depression  and  great  arterial  tension  being  contra- 
indications, he  begins  by  giving  10  to  13  minims  of  the 
wine,  repeating  the  dose  in  an  hour  and,  if  necessary,  two 
hours  later.  The  interval  between  the  doses  is  gradually 
increased,  while  the  amount  is  diminished,  until  a  dose  of 
7  minims  is  reached  ;  this  latter  quantity  is  then  given  three 
times  in  the  twenty-four  hours  as  long  as  the  acute  symp- 
toms last.1  Alkaline  diuretics  are  of  advantage  when  the 
urinary  secretion  is  scant  or  loaded  and  the  skin  generally 
inactive.  Bulkley  advises  the  following  prescription  : 

1$  —  Potassii  acetatis     ........  3iv-  5jss 

Tr.  nucis  vomica?  ........  5ij 

Infus.  quassiae        .....      q.  s.  ad  5iv  —  M. 

S.  —  Teaspoonful  in  water  after  meals. 

In  intractable  cases,  with  frequent  relapses,  Crocker  has 
found  the  application  of  counter-irritants,  mustard  leaves 
or  a  small  blister,  over  the  vasomotor  centres  of  the  parts 
very  beneficial.  If  the  disease  affects  the  upper  half  of 
the  body,  revulsives  may  be  applied  to  the  nape  of  the 
neck;  if  the  lower  half,  they  may  be  put  on  over  the  lumbar 
enlargement. 

In  most  cases  of  localized  eczema  it  is  generally  possible 
to  allay  pruritus  by  properly  selected  topical  agents;  but 
when  the  disease  is  extensive  the  relief  of  the  intolerable 
itching  is  a  matter  of  the  greatest  difficulty.  In  acute 
conditions  absolute  bodily  and  mental  rest  should  be 
enforced,  and  in  suitable  cases  the  antimonial  wine  should 
be  ordered  and  the  patient  put  on  the  customary  fever 
diet.  In  more  chronic  cases,  or  in  less  acute  types  of  the 

1  We  think  these  doses  are  too  large,  and  believe  that  it  would  be 
safer  to  begin  with  5  or  6  minims. 
G 


82  INFLAMMATIONS 

disease,  when  such  means  may  fail,  we  shall  be  forced  to 
try  other  agents.  Opium  is  generally  inadmissible,  on 
account  of  its  increasing  cutaneous  irritability,  anil  should 
be  prescribed  only  as  a  last  resort.  Phenacetin,  chloral, 
sulphonal,  or  some  similar  drug  should  be  tried  first. 
Quinine  in  tolerably  large  doses  often  acts  well.  Pye- 
Smith  recommends  quinine  as  particularly  efficaceous  in 
infantile  eczema;  ^  gr.  for  a  child  of  one  year,  one-half 
hour  before  bedtime;  1  gr.  for  two  years,  and  as  much  as 
5  gr.  at  the  age  of  fifteen.  Pilocarpine  by  the  mouth  or 
hypodermically  is  worth  trying,  but  it  must  be  given  cau- 
tiously. Tincture  of  belladonna  and  the  extract  of  cannabis 
indica  sometimes  act  well.  The  elixir  of  the  valerianate  of 
ammonium  is  helpful  in  nervous  patients. 

The  chloride  of  calcium  is  another  old  remedy  in  eczema 
that  has  again  been  revived,  especially  as  of  value  in  the 
annoying  pruritus.  The  dose  advised  is  20  gr.,  largely 
diluted  with  water,  after  meals.  We  have  seen  it  do  much 
good. 

The  local  treatment  of  eczema  is  of  the  greatest  impor- 
tance. In  quite  a  large  proportion  of  cases  internal  reme- 
dies are  not  demanded  at  all,  either  because  the  disease  has 
been  evoked  by  purely  local  agencies  or  because  the  internal 
exciting  cause  has  ceased  to  be  operative,  and  there  remain 
only  the  effects,  which  must  be  got  rid  of  by  topical  means. 
Although  there  is  a  vast  array  of  preparations  for  applica- 
tion in  eczema,  all  more  or  less  useful  when  judiciously  em- 
ployed, there  are  after  all  two  vital  underlying  principles  that 
should  never  be  ignored.  These  are  rest  and  stimulation. 
Their  application  will  depend  upon  the  stage  in  which  the 
eczema  happens  to  be.  By  rest  is  meant  something  more 
than  the  usual  surgical  significance  of  the  word;  it  means, 
in  the  sense  in  which  we  use  it,  freedom  from  all  sources  of 
possible  irritation — for  example,  not  only  immobilization 
of  a  part,  but  exclusion  of  air,  the  discontinuance  of  the 
irritating  effects  of  soap  and  water,  the  use  of  fixed  dressings 
and,  most  important  of  all,  relief  of  pruritus,  so  that  the 
patient  is  not  constantly  tempted  to  disturb  the  affected 


ECZEMA  83 

surface  by  scratching.  On  the  other  hand,  in  cases  of  a 
more  chronic  character,  when  the  skin  is  greatly  infiltrated, 
the  object  of  treatment  is  to  cause  resorption  of  effused 
material  by  stimulating  remedies,  or  sometimes,  indeed, 
by  using  very  active  local  stimulants  to  induce  an  acute 
and  more  manageable  affection  in  place  of  a  chronic  and 
intractable  one. 

In  order,  however,  to  determine  more  accurately  the 
pathological  state  of  the  skin,  and  to  prepare  it  properly 
for  the  reception  of  the  appropriate  remedy,  it  is  an  absolute 
essential  that  the  parts  be  freed  from  scales,  crusts,  and 
other  secondary  products.  For  the  removal  of  crusts, 
repeated  soakings  in  a  bland  oil  are  much  preferable  to 
poultices.  Occasionally  it  is  allowable  to  use  a  strong 
detersive  soap,  such  as  Bagoe's  olive  soap,  but  as  a  general 
thing  the  rule  never  to  wash  an  eczema  is  to  be  respected. 
So  soon  as  the  stage  of  the  disease  has  been  determined, 
whether  acute,  subacute  or  chronic,  and  all  the  other 
features  of  the  case  have  been  fully  considered,  such,  for 
example,  as  the  age  of  the  patient,  the  length  of  time  the 
eczema  has  existed,  and  also  the  seat  of  the  complaint, 
the  question  will  then  arise  as  to  what  form  of  local  treat- 
ment will  prove  of  the  most  service.  The  proper  answer 
to  this  question  often  makes  the  difference  between  success 
and  failure.  We  shall,  therefore,  now  describe  somewhat 
in  detail  the  various  topical  preparations  that  are  used  in 
eczema,  specifying  the  conditions  to  which  they  are  appli- 
cable, and  after  doing  this  the  clinical  features  and  special 
therapeutics  of  eczema  as  it  affects  the  various  regions  of 
the  body  will  receive  attention. 

Lotions. — According  to  circumstances  lotions  may  be 
soothing,  drying,  and  astringent,  or  stimulating.  They  are 
of  especial  service  in  the  acute  vesicular  form  of  the  disease, 
and  also  in  erythematous  and  papular  eczema.  They 
should  not  be  used  on  hairy  regions  nor  where  there  is  a 
free  discharge.  As  a  rule,  in  case  of  an  acute  inflammation, 
the  lotion  is  to  be  kept  constantly  applied,  renewing  it  as 
often  as  necessary  to  prevent  its  becoming  dry;  under 


84  INFLAMMATIONS 

other  conditions  it  serves  its  purpose  best  by  being  mopped 
on  occasionally  and  allowed  to  dry.  Among  the  soothing 
and  somewhat  astringent  lotions,  useful  in  the  acute  stage, 
may  be  mentioned  the  following: 

3— Tr.  opii, 

Liq.  plumbi  subacetat aa     oij 

Aquae 5iv — M. 

The  following  is  recommended  by  Tay  1  or : 

1$ — Liq.  plumbi  subacetat 3ij 

Tr.  opii 5ij 

Tr.  camphorse 5j 

Glycerini 5ij — M. 

S. — To  be  mixed  with  one  quart  of  water  and  applied  on  lint. 

Dr.  White  recommends  the  black  wash  of  full  strength 
or  dilute  in  the  acute  stage.  He  suggests  that  it  be  mopped 
on  for  ten  to  fifteen  minutes  at  a  time,  and  that  this  should 
be  followed  by  an  application  of  zinc  salve  put  on  with  the 
finger. 

Jamieson  suggests  this  modification : 

1$ — Lotionis  nigrse, 

Liquoris  calcis aa     5iv 

Mucilaginis  tragacanthse 3j — M. 

The  preparation  having,  however,  the  widest  range  of 
application  is  the  well-known  Startin's  lotion,  also  known 
as  the  compound  oxide-of-zinc  lotion  :* 

1$ — Zinci  oxidi 5ss 

Pulv.  calaminac  prsrp 3iv 

Glycerini 5j-ij 

Liquoris  calcis 5vij — M. 

S.— Shake. 
Distilled  or  rose  water  may  be  used  in  place  of  the  lime-water. 

If  a  drying  effect  only  is  desired,  it  may  be  mopped  on 
gently  with  a  soft  rag  or  mopped  or  painted  on  by  means 
of  a  brush.  Otherwise  cheese-cloth  cut  in  strips  may  be 
dipped  into  it  and  bound  on  the  parts  with  a  roller  bandage. 
Carbolic  acid  to  the  amount  of  5  to  10  minims  may  be  added 

1  The  latter  name  will  be  used  in  the  pages  that  follow. 


ECZEMA  85 

to  each  ounce  to  increase  the  antipruritic  effect.  The  itching 
may  still  further  be  allayed  by  the  addition  of  menthol  : 


1$  —  Acidi  carbolic!  ......... 

Mentholis     ..........  3ij 

Alcoholis      ..........  q.  s. 

Lotionis  zinci  oxidi  comp  ......  §iv-viij  —  M. 

This  should  be  mopped  on  as  needed.  Boeck  speaks 
highly  of  this  preparation:  talc  and  starch,  of  each  50; 
glycerin,  20;  lead-water,  100.  This  is  diluted  with  twice 
the  volume  of  water,  and  then  applied  with  a  mop  or  brush. 
In  case  of  a  very  sensitive  skin,  one-half  of  the  lead-  water 
may  be  replaced  by  a  1  per  cent,  boric  acid  solution.1 

Carbolic  acid  lotions  are  of  great  value  in  eczema, 
particularly  as  adjuvants  to  other  treatment: 

1$  —  Acidi  carbolici  .........      oij 

Glycerini      ..........      Sss 

Alcoholis      .......      q.  s.  ad     Sviij  —  M. 

Such  a  lotion  may  be  used  to  advantage  in  connection 
with  a  salve;  thus  the  muslin  bearing  the  ointment  may 
be  lifted  up  and  the  lotion  mopped  on  when  itching  is 
present.  Menthol  can  be  added  to  this  lotion.  Bulkley 
suggests  weak  solutions  of  permanganate  of  potassium  as 
an  antipruritic.  A  drying  lotion  much  in  vogue  among 
English  physicians  is  composed  of  nitrate  of  silver,  16  gr., 
and  sweet  spirits  of  nitre,  1  oz. 

In  the  management  of  chronic,  more  or  less  thickened 
patches,  stimulating  lotions  may  be  found  useful.  One 
such,  warmly  recommended  by  Hutchinson,  is  as  follows: 

1$  —  Liq.  plumbi  subacetatis    ......  rr^x 

Liq.  carbonis  detergentis  ......  3j 

Aquae  destillatae     .....       q.  s.  ad  Oj  —  M. 

S.  —  Mop  on  affected  parts  twice  daily. 

Bulkley  esteems  highly  a  preparation  called  liquor  picis 
alkalinus  : 

1$  —  Picis  liquidse     ......      ,      .      .      3ij 

Potass,  causticse     ........      3j 

Aquse     .......      ....      3v  —  M. 

1  Monats.  f.  prakt.  Uerm.,  August  1,  1895. 


86  INFLAMMATIONS 

This  may  be  used  diluted  (1  to  4  drachms  to  1  pt.  of 
water)  as  an  antipruritic;  or  rubbed  full  strength  into 
localized  patches.  Duhring  has  brought  forward  a  com- 
pound tincture  of  coal-tar  made  thus:  a  strong  tincture 
of  quillaia  bark  is  made  by  adding  1  part  of  the  bark  to 
4  of  95  per  cent,  alcohol.  One  part  of  coal-tar  is  digested 
with  6  parts  of  this  tincture,  with  frequent  agitation,  for 
not  less  than  eight  days.  It  is  to  be  used  in  the  proportion 
of  3  to  15  minims  to  1  oz.  of  water,  to  which  may  be  added 
a  few  minims  of  glycerin. 

Another  very  valuable  stimulating  lotion  is  the  spiritus 
saponatus  kalinus,  made  of  2  parts  of  green  soap  and  1  of 
alcohol.  This  is  to  be  rubbed  well  into  the  affected  part, 
which  should  then  be  washed,  thoroughly  dried,  and 
then  covered  with  diachylon  ointment  spread  on  strips  of 
muslin. 

Tar  may  be  added  in  this  manner: 

1$ — Picis  liquidae, 

Saponis  olivae  praep.,1 

Alcoholis aa     5ij — M. 

Many  other  lotions  are  of  value  containing  salicylic 
acid,  alum,  sulphate  of  zinc,  thymol,  grindelia  robusta, 
etc.;  also  strong  solutions  of  caustic  potash,  but  salicylic- 
acid  has,  today,  largely  superseded  this  latter  agent. 

Powders. — These  preparations  have  not  a  very  wide 
range  of  usefulness  as  regards  the  treatment  of  eczema. 
They  are  indicated  in  the  acute  generalized  erythematous 
variety  and  in  some  subacute  conditions  where  there  is 
little  or  no  secretion.  They  may  prove  of  value  in  certain 
cases  where  lotions  or  salves  are  not  well  borne.  They  may 
be  dusted  on  with  a  powder  puff  or  absorbent  cotton,  or  put 
into  long  quilted  bags  for  permanent  application  to  the  part. 

Anderson's  antipruritic  powder  is  well  known: 

1$ — Pulv.  amyli 3yj 

Zinci  oxidi 3jss 

Pulv.  camphorae 5ss — M. 

1  Bagoe's  soap,  prepared  under  this  name,  is  superior  to  the  im- 
ported green  soap. 


ECZEMA  87 

\ 
Hebra  has  suggested  the  following: 

1$ — Zinci  oxidi, 

Pulv.  aluminis  plumosi, 

Pulv.  rad.  iridis  flor aa     3j 

Pulv.  amyli §ij — M. 

We  have  found  this  powder  excellent  in  eczema  inter- 
trigo : 

1$ — Thymolis gr.  j 

Pulv.  zinci  oleatis 5j — -M. 

The  stearate  of  zinc,  fuller's  earth,  and  emol  keleet  may 
give  good  results.  The  latter  is  said  to  possess  the  property 
of  rendering  hard  water  soft. 

Liniments. — These  will  be  found  useful  when  large  sur- 
faces are  affected,  particularly  if  the  parts  are  red  and 
moist.  The  old-fashioned  carron  oil,  with,  perhaps,  the 
addition  of  1  per  cent,  carbolic  acid,  makes  a  soothing 
application.  Olive  oil  or  oil  of  sweet  almonds  may  be 
substituted  for  the  linseed  oil.  Crocker's  calamine  and 
zinc  liniment  is  rather  more  astringent: 

1$ — Pulv.  calaminse  prsep 9ij 

Zinci  oxidi 5ss 

Olei  olivse, 

Liq.  calcis aa  5j — M. 

Skinner  proposes  the  following  formula: 

1$ — Calaminae  pur 9j 

Zinci  oxidi gr.  xv 

Liq.  calcis 3ss 

Olei  amygdalse  dulcis   .      .      .      .      q.  s.  ad     5j — M. 
Mix  the  powders  with  the  oil,  then  add  the  lime-water  gradually. 

Ointments. — Most  cases  of  eczema  as  seen  in  practice  are 
best  treated  by  ointments.  They  are  especially  indicated 
when  there  is  exudation  and  crusting;  although  they  are  of 
great  service  in  scaly  and  infiltrated  eczemas.  In  order 
that  the  best  results  be  obtained,  the  salve  should  be  per- 
fectly fresh  and  thoroughly  prepared,  and  to  this  end  the 
physician  should  direct  his  patients  to  a  druggist  in  whom 
he  has  perfect  confidence.  It  is  a  good  rule,  in  most  cases, 
to  begin  with  a  soothing  preparation,  feeling  one's  way, 
so  to  speak,  even  though  the  case  appear  to  be  one  requir- 


88  INFLAMMATIONS 

ing  stimulation.  Soothing  ointments  should  usually  be 
spread  on  strips  of  muslin  and  neatly  bound  on  the  parts: 
a  failure  to  observe  this  principle  will  result  in  many 
therapeutic  failures.  If  stimulation  is  required  the  remedy 
may  be  rubbed  in  with  the  fingers.  If  a  mere  protection  of 
the  surface  is  sought,  the  unguentum  aquae  rosae  serves  an 
excellent  purpose.  It  is  also  an  excellent  ointment  base. 
If  a  more  astringent  and  antipruritic  effect  is  desired,  the 
following  formula  is  admirable: 

1$ — Bismuth!  subnitratis 5ss 

Acidi  carbolic! n\v-x 

Ung.  aq.  rosae 5j — M. 

A  very  useful  application  in  many  conditions  is  the  ben- 
zoated  oxide-of-zinc  preparation  of  Wilson.  1  drachm 
of  the  dilute  solution  of  the  subacetate  of  lead  may  be  added 
to  increase  its  sedative  action,  and  the  same  quantity  of  the 
tincture  of  camphor  may  be  incorporated  for  itching,  if 
this  is  a  prominent  symptom. 

JamiesonV  ophthalmic  ointment  is  a  very  soothing 
application  for  eczematous  eyelids : 

1$ — Olei  amygdalae  dulcis, 

Aquae aa     oss 

Lanolin! 5"j — M. 

To  this  may  be  added  zinc  oxide  or  bismuth. 
Other  formulae  are  as  follows : 

1$ — Zinc!  carbonatis oj 

Acidi  salicylici gr.  x 

Vaselini  .      .      .  • oj 

Ung.  aq.  rosae 5j — M. 

Jamieson. 

1$ — Bismuthi  oxidi 3jss 

Acidi  oleici Sjss 

Cerae  albae 5v 

Vaselini 5ij 

Olei  rosae njj — M. 

Anderson. 

1  Brit.  Jour.  Derm.,  May,  1897. 


ECZEMA  89 

]$ — Glycerol.  plumbi  subacetatis  (Squire)  5j 

Ung.  aq.  rosse 3j 

Cera?  alba3 q.  s. — M. 

1$ — Bismuth!  subnitratis 3j 

Ung.  aq.  rosse 3j— M. 

An  ointment  of  great  value  in  so-called  seborrheal 
eczema  is  as  follows: 

1$ — Acidi  salicylici 9j-3ss 

Sulphuris  prsecip 3j-5ij 

Vaselini 3j 

Olei  limonis q.  s. — M. 

Resorcin  in  the  strength  of  from  1  to  20  per  cent,  may 
be  substituted  for  the  salicylic  acid  in  the  above.  Lanolin 
combined  with  20  per  cent,  of  cold  cream  affords  a  tena- 
cious and  soothing  unguent  to  the  inflamed  skin. 

One  of  the  most  universally  applicable  and  valuable 
ointments  is  the  unguentum  diachylon  of  Hebra,  but  as 
the  original  formula  is  very  difficult  to  prepare,  it  is  now 
usually  made  in  the  following  manner: 

1$ — Emplastri  diachyli, 

Vaselini ..      .      .      .    aa.    5j 

Olei  lavandulse  (vel  ol.  geranii)    ....       q.  s. — M. 

Melt  the  lead  plaster  and  vaselin  together  by  gentle 
heat,  stirring  constantly.  Then  add  the  oil  of  lavender  or 
geranium.  If  the  lead  plaster  is  fresh  it  is  best  to  remove 
the  irritating  glycerin  by  a  water  bath.  This  preparation 
is  now  generally  known  as  unguentum  vaselini  plumbicum. 
Various  drugs  may  be  added  to  this  salve,  as,  for  example, 
tar,  phenol,  boric  acid,  oxide  of  zinc,  starch,  etc.  The 
application  should  be  made  as  directed  above,  viz.,  on 
cloth.  This  latter  point  cannot  be  impressed  too  firmly 
upon  the  physician.  A  formula  of  great  value,  especially 
in  infantile  eczema,  is  the  following: 

~fy — Zinci  oxidi 3j 

Pulv.  amyli 3ij 

Ung.  picis  liq 3j-5ij 

Ung.  vaselini  plumb q.  s.  ad  5j — M. 

S. — Spread  on  strips  of  lint  or  muslin. 


90  INFLAMMATIONS 

Here  only  sufficient  tar  has  been  added  to  allay  itching. 
The  various  preparations  of  tar  are  of  great  value  in  eczema , 
but  it  is  an  agent  that  cuts  both  ways.  If  a  stimulating 
effect  is  desired  the  stronger  preparations  should  be 
employed,  thus: 

1$ — Otei  nisei      ...» 5j-oij 

Ung.  aq.  rosae 5j — M. 

Such  a  prescription  is  especially  useful  in  the  squamous 
forms  of  the  disease,  and  in  such  cases  it  should  be  rubbed 
thoroughly  into  the  skin  two  or  three  times  in  twenty-four 
hours. 

As  regards  other  medicaments  that  can  be  employed  in 
the  treatment  of  eczema  in  the  form  of  salves,  may  be 
mentioned  carbolic  and  salicylic  acids,  tannin,  sulphur, 
acetanilid,  and  mercury. 

The  mercurials  are  of  great  value,  but  should  be  applied 
with  caution  for  fear  of  absorption.  Duhring  speaks  well 
of  calomel  in  the  strength  of  £  to  1  drachm  to  1  oz. 
Niemeyer  extolled  the  virtues  of  the  white  precipitate. 
We  have  got  much  satisfaction  from  it  in  the  strength  of 
from  20  to  60  gr.  to  1  oz.,  or  combined  with  tar: 

1$ — Hvdrajg.  ammoniati 3ss 

Liq.  pkris  «Ilr»lini 5  j 

Ung.  aq.  nwae 3j — M. 

Pastes. — In  recent  years  pastes  have  to  a  certain  extent 
taken  the  place  of  salves  in  the  treatment  of  eczema, 
especially  where  an  ointment  proves  irritating.  They  are 
usually  made  with  vaselin,  to  which  is  added  a  large 
quantity  of  an  inert  powder,  with  a  small  amount  of  the 
active  ingredient.  The  resulting  preparation,  when  smeared 
on  the  skin,  quickly  dries,  leaving  a  protective  coating. 
Pastes  are  better  adapted  for  dry  than  for  moist  surfaces. 

One  of  the  best  is,  undoubtedly,  that  of  Lassar: 

B — Acidi  flatievlici gr.  x 

Zinci  oxidi, 

Pulv.  amyli aa  oij 

Vaadini 5w— M. 


ECZEMA  91 

G.  H.  Fox's  is,  perhaps,  even  better: 

R  —  Acidi  salicylici  .........  g*"-* 

Pulv.  amyii. 

Bismuthi  subnitrat.      ......  aa  oiij 

Ung.  aq.  rase    ......      q.  &.  ad  5  j  —  M. 

The  writers  suggest  the  addition  of  5  per  cent,  ofl  of 
cade  when  more  stimulation  is  needed. 

Such  pastes  may  be  spread  on  muslin,  or  rubbed  directly 
in  if  the  condition  be  chronic  and  scaly.  They  are  useful  in 
eczema  intertrigo.  We  have  employed  the  following  with 
excellent  results: 

R  —  Bismuthi  subnitrat.      .......  onr 

Zinci  oxidi    ..........  5  j 

Pair,  amrli  ..........  5«j 

Acidi  carbolki    .........  ^y-  xv 

Yasdini  (vel  ung.  aq.  roes-)     .      .      q.  s.  ad  5  j  —  M. 

Ihle's  paste  is  made  after  the  following  manner: 
Q  —  Resorcini      ..........     gr.  x—  D 


Pubr.  amvli. 

aa     oij  —  ^M- 


The  Unimentum  exskcans  of  Pick  is  a  very  Tamable 
preparation  in  erythematoos  and  papular  eczemas,  unless 
there  is  much  exudation  and  infiltration: 

R  —  Tragacuithx-      .........     «r.  bonr 

CHycefini       ..........     n^xts 

Agor  deatiliiti       ........     oxx^^e  —  M. 

An  excellent  protective  coating  is  obtained  by  adding  10 
per  cent,  of  oxide  of  zinc  and  1  per  cent,  of  carbolic  acid 
to  the  above. 

Dr.  Elliot's  bassorin  paste  is  as  follows: 

R—  Bassoon        ..........      ox 

Dextrin  .     ......     ....     o^j 


Aqme  destflatax      .....     q.  &  ad     5xxv»—  M. 

.  :••.  v..'.";   :•;  .  '. 


92  INFLAMMATIONS 

It  may  be  medicated  as  desired.  When  large  surfaces 
are  involved,  Unna's  oxide  of  zinc  paste  serves  an  admirable 
purpose : 

1^ — Zinci  oxidi 5j 

Mucilaginis  acacise, 

Glycerin! .   aa     3ij — M. 

S. — Apply  with  a  brush  several  times  daily. 

One  per  cent,  carbolic  acid  may  be  added  when  itching 
is  present.  If  the  glycerin  disagrees,  oil  of  sweet  almonds 
affords  a  less  irritating  menstruum. 

Glycerin  Jelly. — Some  years  since,  Professor  Pick,  of 
Prague,  suggested  the  employment  of  gelatin  as  a  vehicle 
for  various  medicaments  and  as  a  protective  coating.  Such 
preparations  are  to  be  used  in  the  same  class  of  cases  as 
the  pastes.  They  are  somewhat  difficult  of  preparation. 
Unna  and  Beiersdorf  combined  the  gelatin  and  glycerin 
directly  and  found,  moreover,  that  a  definite  relation  must 
exist  between  the  amounts  of  gelatin,  glycerin,  and  water 
taken  and  the  percentage  of  drug  employed.  One  of  the 
best  formulae  is  as  follows : 

1^ — Gelatinse 3jv 

Zinci  oxidi    . Sijss 

Glycerini 3j 

Aquae  destillatae 3x — M. 

Heat  the  water,  dissolve  the  gelatin  in  it,  then  add  the 
glycerin  and  zinc  oxide  and  stir  until  cold.  One-half  per 
cent,  of  ichthyol  may  be  added.  The  gelatin  is  prepared  for 
use  by  melting  in  a  hot-water  bath ;  the  liquefied  material 
is  then  painted  on.  While  moist  cover  the  jelly  with  tissue 
paper.  Jamieson  praises  this  method  of  treatment  en- 
thusiastically. Gelanthum,  a  preparation  introduced  by 
Unna,  has  been  slightly  modified  by  Skinner: 

T$ — Tragacantlue oijss 

Gelatin,  opt oij 

Glycerini 5vj 

Thymolis gr.  J 

Aquae  destillatae q.  s. — M. 

Place  the  tragacanth  and  gelatin  each  in  10  oz.  of 
water  in  covered  jars,  and  bring  the  final  quantity  up  to 


ECZEMA  93 

12  oz.  with  water.    Other  drugs,  with  the  exception  of 
acetate  of  lead,  may  be  added  as  desired. 

Plasters.  —  The  germ  of  the  idea  of  fixed  dressings  may, 
perhaps,  be  found  in  Hebra's  method  of  spreading  salves 
on  strips  of  lint.  Of  late  years  many  methods  of  making 
continuous  applications,  in  eczema  and  other  diseases  of 
the  skin,  have  been  introduced,  and  among  the  most 
valuable  are,  doubtless,  the  various  forms  of  plasters.  The 
plaster  and  salve  mulls  of  Unna  possess  great  merit,  and 
can  now  be  obtained  in  this  country.  The  chief  difficulty 
is  to  get  them  in  a  fresh  condition.  The  salve  mulls  are 
prepared  by  incorporating  the  desired  remedy  with  a  base 
made  usually  of  benzoated  suet  and  lard,  and  this  is  spread 
on  one  or  both  sides  of  undressed  muslin.  The  plaster 
mulls  are  made  of  gutta-percha  faced  with  some  adhesive 
substance  containing  the  medicament,  and  backed  with 
muslin.  The  diachylon  mull  is  of  great  value  in  subacute 
eczema.  The  salicylic  acid  plaster  mull  does  excellent  ser- 
vice in  deeply  infiltrated  patches  on  the  hands  and  feet. 
Of  late  years,  however,  these  plaster  mulls  have  been  in  a 
great  measure  replaced  by  Pick's  salicylated  soap  plaster 
or  some  modification  of  it  : 


1$  —  Emplast.  saponis  liq  ....... 

Olei  plivse  ..........      3v 

Acidi  salicylic!       ..."     .....     gr.  xxxvj  —  M. 

Klotz's  modification  is  thus  prepared:  Diachylon 
plaster,  60;  soap  plaster,  25;  yellow  wax,  2;  vaselin,  8; 
salicylic  acid,  5.  For  a  5  per  cent,  plaster  no  olive  oil  is 
required,  the  salicylic  acid  softening  the  mass  sufficiently. 
Duhring's  formula  for  a  20  per  cent,  plaster  is:  Lead 
plaster,  §  j  ;  yellow  wax,  gr.  xlviij  ;  salicylic  acid,  gr.  cv. 

The  formula  that  we  usually  employ  is  as  follows: 

1^—  Emplast.  plumbi   ........  3xxv 

Pulv.  saponis   .........  9iv 

Aquae  dest  ..........  q.  s. 

Vaselini       ..........  ov 

Camphorae  ..........  gr.  xx 

Acidi  salicyliei        ........  3v  —  M. 

S.  —  Spread  on  muslin. 


94  INFLAMMATIONS 

Make  a  paste  with  the  soap  and  water;  add  the  lead 
plaster  and  evaporate  to  a  proper  consistency;  then  add 
the  vaselin,  salicylic  acid,  and  camphor.  Melt  together 
with  a  gentle  heat.  The  percentage  of  salicylic  acid  may 
be  increased  as  necessary,  and  the  plaster  diluted  by  add- 
ing unguentum  vaselini  plumbicum.  These  plasters  may 
be  left  in  situ  for  several  days  if  agreeable  to  the  patient. 
They  are  especially  useful  in  infiltrated  eczemas. 

Paints. — Similar  in  object  and  in  action  to  the  other 
fixed  dressings  are  the  pigments  made  with  collodion  and 
traumaticine.  Various  medicaments  may  be  introduced 
into  these  liquids.  In  small,  infiltrated  patches  of  eczema, 
salicylic  acid  and  chrysarobin,  of  each  5  to  10  per  cent., 
are  valuable. 

The  following  is  often  useful  in  eczemas  about  the 
mouths  of  children: 

1$ — Olei  cadini 3j 

Collodii  (vel  traumaticini) Bj — M. 

S. — Apply  with  a  camel's-hair  pencil. 

It  should  be  borne  in  mind  that  in  adding  an  oil  to 
collodion  the  contractile  variety  should  be  prescribed, 
since  the  addition  of  an  oil  to  the  flexible  preparation  will 
render  it  too  flexible. 

Piffard  holds  that  contractile  collodion  will  at  times 
abort  a  threatened  eczema,  or,  if  painted  around  the  margin 
of  an  existing  lesion,  tend  to  prevent  its  extension. 

Acetic  cantharidal  collodion  is  often  useful  as  a  blistering 
agent  in  small  chronic  patches  of  eczema. 

Tar,  as  an  ethereal  and  alcoholic  tincture,  may  be  advan- 
tageously employed  as  a  paint,  the  region  being  afterward 
dusted  over  with  an  indifferent  powder.  Leistikow  regards 
coal-tar  as  a  better  antipruritic  than  wood-tar.  He  advises 
it  especially  in  dry  eczema  of  the  scalp,  neck,  and  external 
genitals.  Care  should  be  observed  lest  poisoning  occur. 

1$ — Coal-tar Sjss 

Alcohol  (95  per  cent.) 3j 

Sulphuric  ether 5ss — M. 

S. — Apply  with  a  brush. 


ECZEMA  95 

Baths. — It  may  be  stated  as  a  broad  general  rule,  that 
water  in  any  form  is  harmful  in  eczema.  The  less  an 
eczematous  surface  is  bathed  the  better  for  it,  particularly 
in  the  acute  forms.  With  the  exception  of  occasional 
alkaline  baths  in  generalized  papular  eczema,  they  are  now 
but  little  prescribed.  The  general  tonic  effect  of  sea-bath- 
ing may  sometimes  benefit  chronic  localized  patches,  as 
may  also  the  various  mineral  and  thermal  springs  of  this 
country,  provided  intelligent  local  treatment  be  carried 
out  at  the  same  time.  At  springs  the  copious  drinking  of 
the  water,  together  with  proper  diet  and  hygiene,  may  often 
give  gratifying  results.  For  cleansing  an  eczematous  sur- 
face, warm  milk  and  water,  or  olive  oil  applied  on  cotton 
wool,  serves  better  than  water. 

Massage,  Scarification,  and  Mechanical  Support. — 
Massage  is  occasionally  of  value,  and  is  indicated  particu- 
larly in  chronic,  infiltrated  forms  of  eczema;  as  a  conse- 
quence of  such  stimulation  of  the  absorbents  the  exudation 
is  dissipated,  the  thickening  decreases,  and  the  pruritus  is 
lessened.  Multiple  punctures  and  scarification  may  occa- 
sionally prove  of  benefit  in  very  chronic  patches  of  eczema. 
The  rubber  web  bandage  affords  beneficial  support  and 
compression  in  suitable  cases,  particularly  when  applied 
to  the  leg. 

Having  now  given  a  brief  general  outline  of  the  various 
internal  and  local  measures  that  are  useful  in  the  manage- 
ment of  eczema,  we  shall  next  proceed  to  a  description  of 
the  special  forms  of  the  disease: 

Eczema  of  the  Scalp. — In  this  region  the  disease  may 
assume  various  elementary  types,  viz.:  erythematous, 
vesicular,  squamous  and  pustular,  but  the  physician  rarely 
encounters  it  in  this  stage,  his  advice  being  sought,  as  a 
rule,  only  when  secondary  changes  have  supervened. 
Thus,  the  case  may  present  more  or  less  widespread 
yellowish-green  crusts,  that  sometimes  cover  the  part  like 
a  cap;  or  the  surface  is  moist,  the  hair  glued  together;  or 
the  eruption  maybe  infiltrated,  scaly,  and  intensely  itchy. 
These  various  states  may  be  present  at  one  and  the  same 


96  INFLAMMATIONS 

time,  but  it  is  more  usual  to  find  one  or  the  other  predomi- 
nating, or  else  the  sole  form  of  eczema  present.  The 
erythematous  variety  may  commence  as  such,  or  it  may 
supervene  upon  the  other  forms.  Pustular  eczema  of  the 
scalp  is  most  often  seen  in  children,  and  extension  to  the  face 
and  ears  is  of  frequent  occurrence.  It  is  further  attended 
in  most  cases  by  postcervical  adenopathy.  These  swollen 
glands  rarely  suppurate. 

Seborrhea  is,  perhaps,  the  most  common  exciting  cause 
of  eczema  of  this  region. 

Treatment. — The  internal  treatment  requires  no  special 
comment,  beyond  that  in  the  pustular  variety,  particu- 
larly in  children,  cod-liver  oil,  iron,  or  other  tonic  meas- 
ures are  often  demanded.  In  both  children  and  adults 
the  first  step  necessary  is  the  removal  of  crusts,  if  present. 
This  is  done  best  by  soaking  in  olive  or  cod-liver  oil; 
poultices  should  be  avoided.  In  children  the  hair  may  well 
be  clipped,  but  this  would  be  objectionable,  for  obvious 
reasons,  in  adults,  especially  women. 

Stiff  ointments  should  not  be  applied  to  hairy  regions, 
preparations  having  vaselin,  oil,  alcohol,  glycerin,  or 
water  as  excipients  being  more  suitable.  The  acute  forms 
of  eczema  require  soothing  applications,  and  for  this  pur- 
pose may  be  employed  oil  of  sweet  almonds  or  sweet  oil, 
containing  1  per  cent,  of  carbolic  acid,  or  a  lotion  of  the 
black  wash  mopped  on  for  a  few  minutes  at  a  time,  followed 
by  a  reapplication  of  the  oil,  or  an  ointment  composed  of 
bismuth  (subnitrate),  5J5  vaselin,  §j. 

In  young  infants,  or  where  the  hair  has  been  cut  close, 
the  unguentum  vaselini  plumbicum,  spread  on  strips  of 
muslin  and  held  in  place  by  a  snugly  fitting  cap,  affords 
a  valuable  dressing.  The  addition  of  1  drachm  of  boric 
acid  to  1  oz.  is  often  beneficial.  After  the  subsidence  of 
the  inflammatory  symptoms,  or  in  the  subacute  condi- 
tion, we  have  derived  the  greatest  satisfaction  from  the 
following: 


ECZEMA  97 

IJ — Ung.  picis  liquidse 3j-ij 

Zinci  oxidi 3j 

Ung.  aq.  rosae 3j — M. 

S. — Spread  on  strips  of  cloth.    Change  twice  daily. 

In  acute  pustular  eczema,  Duhring  recommends  ichthyol, 
gr.  x-xx;  olive  oil,  §j,  and  in  the  subacute,  discharging 
form  a  salicylic  acid  salve  of  from  25  to  40  gr.  to  1  oz. 
Calomel  and  white  precipitate  are  valuable,  in  ointment 
form,  if  used  cautiously  over  a  limited  area.  The  scalp 
bears  tar  remarkably  well,  and  in  most  cases  of  a  chronic 
type  it  may  be  applied  in  the  form  of  an  oil. 

1$ — Olei  rusci  3j 

Olei  amygdalae 3j — M. 

S. — Apply  with  dropper. 

J^ — Olei  rusci 3j 

Glycerin! 3j 

Alcoholis 3vj 

Olei  rosae q.  s. — M. 

Somewhat  more  pleasant  and,  we  believe,  more  efficacious 
in  chronic,  scaly  eczema  of  the  scalp,  is  this  prescription : 

fy— Acid!  salicylic! 9j 

Sulphuris  praecip 3j 

Vaselini 3j 

Olei  limonis q.  s. — M. 

S.— Work  thoroughly  into  the  scalp  once  or  twice  daily. 

Resorcin  in  from  3  to  20  per  cent,  strength  may  be  sub- 
stituted for  the  salicylic  acid. 

In  refractory  cases  an  ointment  as  follows  is  often  useful : 

1^ — Acidi  tannici 3j 

Acidi  carbolici TT^V-X 

Cerati  Galeni 3j — M. 

Or  this: 

1$ — Hydrarg.  ammoniati 9j 

Liq.  carhonis  detcrg 5j 

Vaselini 3j — M. 

In  very  obstinate,  moist  ec/emas,  Duhring  and  others 
advise  a  1  to  2  per  cent,  silver  nitrate  solution,  applied 
daily  or  less  often  and  followed  by  a  mild  salve.  In  these 


98  INFLAMMATIONS 

cases  it  will  be  necessary,  now  and  then,  to  remove  from 
the  part  the  accumulation  of  salve,  scales,  etc.  For  this 
purpose  in  acute  cases,  as  before  stated,  oils  should  be 
used.  In  more  chronic  conditions  soap  and  water  may  be 
employed  if  caution  is  observed,  but  even  then  it  should  be 
as  infrequently  as  possible. 

Bagoe's  green  soap  and  alcohol,  or  cologne,  equal  parts, 
or  from  3  to  6  teaspoonfuls  of  borax  or  carbonate  of  soda 
to  1  pt.  of  water  may  be  used.  Immediately  after  the 
washing,  vaselin,  oil,  or  the  salve  should  be  reapplied. 

If  the  eczema  is  set  up  by  the  ravages  of  pediculi,  they 
should,  of  course,  be  removed  at  once,  together  with  their 
nits. 

Eczema  of  the  Face. — Any  variety  of  eczema  may  occur 
on  the  face,  the  erythematous,  however,  being  more  com- 
mon in  adults,  and  the  vesicular,  papular,  and  pustular 
types  in  children.  The  erythematous  form  is  prone  to 
attack  individuals  past  middle  life  and  is  an  exceedingly 
stubborn  affection  and  subject  to  relapses.  It  generally 
develops  suddenly  and  at  first  may  be  mistaken  for  erysipe- 
las. It  usually  involves  the  forehead,  nose,  cheeks,  and 
eyelids,  the  latter  often  being  completely  closed  from  the 
attendant  swelling.  The  skin  is  of  a  dusky-red  color, 
edematous,  and  the  itching  and  burning  are  very  severe. 
In  chronic  types  the  skin  becomes  leathery,  the  lids  are 
stiff  with  infiltration,  deep  fissures  occupy  the  natural 
furrows  and  wrinkles  of  the  skin,  and  the  surface  is  covered 
with  fine  scales,  except  that  here  and  there  have  been 
developed  raw  and  oozing  points  due  to  scratching. 

Oftentimes  a  certain  amount  of  papular  eczema  is  seen 
to  accompany  this  form  of  the  disease.  Itching  is  well- 
nigh  intolerable  and  occurs  usually  in  paroxysms.  In 
cases  of  long  standing,  ectropion  may  result  from  the  infil- 
tration of  the  lids. 

In  children  the  elementary  forms  are  more  often  ob- 
served, but  ordinarily  the  secondary  results  only  are 
seen  by  the  physician,  viz.,  red,  scaly,  and  slightly  thick- 
ened patches,  or  red  and  exuding  surfaces  more  or  less 


ECZEMA  99 

covered  with  crusts  and  scales,  or,  again,  the  underlying 
surface  may  be  entirely  covered  with  thick  crusts.  This 
form  of  the  disease  is  often  accompanied  by  a  similar  condi- 
tion of  the  scalp  and  ears,  and  is  then  known  in  common 
parlance  as  "  crustea  lactea"  or  "  milk  crust."  The  itching 
is  excessive,  and  in  order  to  get  relief  the  parts  are  remorse- 
lessly torn  with  the  nails,  so  that  the  whole  face  at  times  is  a 
mass  of  crusts  made  up  of  pus  and  blood  with  here  and 
there  deep  excoriations.  In  young  infants,  that  cannot 
use  the  hands,  the  face  is  rubbed  against  the  pillow  or 
nurse's  shoulder. 

Pustular  eczema  of  the  upper  lip  is  not  infrequent  and 
the  lip  may  be  considerably  tumefied  and  the  nares  partially 
occluded.  • 

Treatment. — In  acute  erythematous  eczema  of  the  adult 
face,  treatment  should  be  of  a  soothing  character,  lotions 
being  preferable : 

1$ — Zinci  oxidi 5ss 

Pulv.  calaminse  prsep 3iv 

Glycerin! Bj 

Liq.  calcis 5vij — M. 

S. — Mop  on  or  apply  on  cheese-cloth  cut  to  fit  the  parts. 

1$ — Zinci  oxidi 5ss 

Mucilag.  acacise 5j 

Emuls.  amygdalae 5ij 

Aquae  rosse q.  s.  ad  5iv — M. 

S. — Smear  on  gently  every  few  hours. 

If  an  ointment  seems  to  suit  better,  the  unguentum 
vaselini  plumbicum  serves  a  good  purpose ;  or  this : 

!$ — Glycerol.  plumbi  subacetat  (Squire)  .      .      .      3ss 

Ung.  aq.  rosaj 5j 

Cerse  albse q.  s. — M. 

It  is  well,  in  these  acute  cases,  to  secure  a  free  action  of 
the  bowels,  employing  for  this  purpose  the  mistura  ferri 
acida,  or  some  similar  prescription. 

In  cases  of  a  less  inflammatory  type,  with  moderate 
infiltration,  the  zinc-ichthyol  gelatin  is  valuable,  or  the 
zinc  and  tar  salve  may  be  cautiously  tried.  As  many 


100  INFLAMMATIONS 

patients  are  unwilling  to  wear  ointments  and  lotions  during 
the  day,  and  in  this  lies  the  main  difficulty  in  effecting  a 
cure,  the  parts  may  be  protected  by  Provan's  paste: 

1$ — Tragacantha?, 

Glycerini aa  3iv 

Boracis 5ss 

Aquae  destillatse q.  s. — M. 

This  may  be  washed  off  at  night.  If  preferred,  powdered 
oleate  of  zinc  may  be  dusted  on. 

When  the  disease  is  limited  to  the  forehead,  the  diachy- 
lon salve  mull  may  be  constantly  worn  under  the  inner 
hat-band.  This  so-called  "sweat  band"  is  a  prolific  source 
of  eczema,  and  in  the  interest  of  susceptible  skins  we  are 
accustomed  to  order  that  a  piece  of  soft  cotton  cloth  be 
pasted  over  the  part  that  comes  in  contact  with  the  forehead. 

In  our  experience,  even  in  very  chronic  eczema  of  the 
face,  frictions  with  green  soaps  and  strong  preparations  of 
tar  are  ill-borne;  but  we  find  that  the  compound  salicylic 
plaster  (see  under  Plasters),  neatly  spread  on  muslin  and 
adjusted  to  the  parts,  is  of  great  value.  We  usually  employ 
the  5  per  cent,  preparation. 

Duhring  suggests  a  formula  for  the  same  purpose : 

1$ — Camphorse 5ss 

Empl.  plumbi oiij 

Petrolati oiij 

Olei  olivsc oj — M. 

In  certain  scaly,  more  or  less  well-defined  patches  seen 
on  the  cheeks  and  about  the  mouth,  the  following  is 
valuable : 

1^ — Hydrarg.  ammoniati 9j 

Liq.  carbonis  detergentis 5j 

Lanolini 5j — M. 

In  children  the  crusts  should  be  removed  by  inunctions 
with  sweet  oil,  or  by  applying  at  once  the  unguentum 
vaselini  plumbicum  spread  on  muslin  strips.  This  latter 
may  then  be  continued  as  the  remedial  agent.  As  a  routine 
prescription  in  almost  all  types  of  ec/eina  in  children, 
especially  eczema  rubrum,  the  following  prescription, 


ECZEMA  101 

which  we  have  called  the  "  compound  starch  ointment," 
has  the  widest  range  of  usefulness: 

1$ — Zinci  oxidi OJ 

Pulv.  amyli 5ij 

Ung.  picis  liq 5jj 

Ung.  vaselini  plumb q.  s.  ad  3j — M. 

In  warm  weather  the  amount  of  starch  may  be  increased. 
In  place  of  the  tar,  2  to  3  minims  of  carbolic  acid  may  be 
added  to  each  ounce;  and  instead  of  the  oxide  of  zinc,  an 
equivalent  quantity  of  boric  acid.  In  most  cases,  how- 
ever, the  formula  as  given  is  the  best.  The  bismuth,  zinc, 
and  starch  preparation  as  given  above  under  Pastes  is 
of  value.  For  children  the  amount  of  carbolic  acid  should 
be  decreased.  As  a  rule,  salves  should  be  applied  on 
strips  of  muslin  and  kept  in  place  by  a  light  skeleton 
mask.  Lassar's  paste  used  in  this  way,  or  lightly  smeared 
on,  in  papular  and  scaly  eczema,  is  a  valuable  remedy.  It 
dries  to  a  thin  adhesive  powder,  which  allays  itching,  and 
is  not  readily  scratched  off.1 

It  is  especially  true  of  the  eczema  of  children  that  the 
affected  surface  must  not  be  washed,  as  thereby  all  the 
good  accomplished  by  the  remedy  in  days  is  sacrificed  in 
a  few  minutes. 

Eczema  about  the  mouth  is  quite  difficult  to  heal,  particu- 
larly in  children,  owing  to  the  free  motions  of  the  parts,  the 
irritating  effects  of  nasal  discharges,  saliva,  the  passage  of 
food,  etc.  Here  a  fixed  dressing  is  necessary  and  we  are  in 
the  habit  of  employing  the  following  pigment,  after  first 
removing  the  crusts: 

1$ — Olei  rusci 5ss-oj 

Collodii  (contractilis)  vel  traumaticini    .      .      3j — M. 

The  linimentum  exsiccans  or  gelanthum,  to  which  10 
per  cent,  of  oxide  of  zinc  has  been  added,  makes  a  good 
application  for  this  purpose,  and  is  less  irritating  than  the 
tar  and  collodion. 

1  Unless  these  pastes  are  well  made  they  do  more  harm  than  good. 


102  INFLAMMATIONS 

Eczema  of  the  Ears. — The  various  forms  of  the  disease 
are  to  be  seen  in  this  situation.  Children  are,  perhaps, 
more  often  affected,  especially  in  connection  with  eczema 
of  the  face  or  scalp;  but  it  may  easily  occur  in  adults,  when 
it  is  often  on  the  ears  alone,  and  is  usually  symmetrical. 
The  otologist  generally  meets  those  cases  of  acute  or  chronic 
eczema  that  involve  the  external  auditory  meatus. 

In  the  acute  type  the  ears  are  red,  swollen,  and  tender; 
in  the  chronic  cases  the  parts  are  board-like,  fissured,  and 
scaling.  Exacerbations  and  relapses  are  frequent.  In 
eczema  of  the  external  meatus,  the  patient  complains  of 
deafness,  pruritus,  and  a  feeling  of  fulness.  The  canal 
becomes  clogged  with  scales  and  cerumen. 

Treatment. — In  acute  eczemas  of  the  auricle  soothing 
remedies  are  indicated,  as,  for  example,  the  compound 
zinc  lotion,  or  the  oxide  of  zinc  and  almond  emulsion. 
Ointments  are  more  useful  in  subacute  and  chronic  cases, 
the  best,  perhaps,  being  the  modified  diachylon,  which 
should  be  applied  on  cloth.  In  very  chronic  cases,  the  5 
per  cent,  salicylic  acid  plaster  will  quickly  reduce  the 
infiltration.  In  those  very  persistent  eczemas  that  occur 
behind  the  ears  of  children,  a  brisk  application  of  green 
soap,  followed  by  the  unguentum  vaselini  plumbicum,  is 
especially  useful.  For  the  itching,  a  carbolic  acid  lotion 
may  be  mopped  on : 

1$ — Acidi  carbolic! 5ss 

Glycerini TT^XV 

Alcoholis oj 

Aq.  rosae q.  s.  ad  5iv — M. 

Eczema  of  the  Nares. — The  disease  in  this  situation  is 
often  associated  with  chronic  nasal  catarrh,  and  in  children 
frequently  follows  in  the  wake  of  the  exanthemata.  It  is 
to  be  distinguished  from  lupus  and  syphilis.  The  nose  is 
often  swollen  and  the  nasal  orifices  almost  closed  with 
crusts.  The  nostrils  may  be  infiltrated  and  cracked.  The 
disorder  may  be  confined,  however,  to  the  alae.  On  remov- 
ing the  crusts,  the  Schneiderian  membrane  will  be  found 
reddened  and  congested  with,  at  times,  considerable 


ECZEMA  103 

ulce ration.  The  surface  may  show  a  discharge  or  be  in  a 
dry,  glazed  condition.  A  follicular  eczema  of  the  hair 
follicles  within  the  nares  is  not  uncommon  in  the  adult, 
and  is  quite  persistent  and  painful.  Pustular  eczema  of 
the  upper  lip  is  a  frequent  accompaniment. 

Treatment. — These  cases  require  that  the  general  health 
receive  proper  attention.  Cod-liver  oil  and  syrup  of  the 
iodide  of  iron  are  useful  in  children,  and  as  the  follicular 
eczema  of  adults  usually  indicates  debility,  it  must  be  treated 
accordingly.  Crusts  should  be  first  removed  by  inunc- 
tions with  oil,  and  afterward  soothing  and  slightly  astrin- 
gent ointments  applied.  For  this  latter  purpose  boric  salve 
and  weak  ointments,  5  to  20  gr.  to  1  oz.,  of  white  pre- 
cipitate or  calomel  are  suitable.  Squire's  glycerole  of  the 
subacetate  of  lead,  1  drachm  to  1  oz.  of  cold  cream,  is 
soothing  and  healing.  If  the  condition  is  distinctly  pus- 
tular, the  following  preparation  acts  promptly. 

Iff — Xeroformi         gr.  xx-lx 

Vaselini 3ij 

Lanolini 3vj — M. 

Unna  suggests  that  small  rolls  of  paper  covered  with 
zinc  and  red  precipitate  salve  mull  should  be  inserted  into 
the  nostrils. 

Eczema  of  the  Lips. — The  vermilion  surface  of  the  lips 
is  sometimes  the  seat  of  an  exuding  or  squamous  eczema, 
the  latter  being  often  accompanied  by  painful  cracks  and 
fissures.  These  are  the  more  frequent  varieties.  As 
already  stated,  the  cutaneous  portion  of  the  upper  lip  is 
often  the  seat  of  a  pustular  eczema  and  this  is  particularly 
obstinate  if  there  is  a  mustache. 

Treatment. — The  treatment  of  the  disease  as  seen  on  the 
vermilion  border  is  highly  unsatisfactory.  Acute  condi- 
tions should  be  soothed;  thus,  lanolin  with  20  per  cent, 
cold  cream  may  be  tried;  or  the  following  bismuth  oint- 
ment: 

1$ — Bismuth!  subnit 3ss 

Aquse 3j 

Ol.  amygdalae  dulcis 3j 

Lanolini 3vj— M. 


1 04  IN  FLAM  MA  TIONS 

G.  H.  Fox  recommends  5  gr.  of  thymol  to  1  oz.  of 
cold  cream,  especially  in  squamous  conditions.  The  5 
per  cent,  salicylic  acid  plaster  is  also  useful.  Where  there 
is  much  thickening,  strong  solutions  of  caustic  potash,  20 
gr.  to  1  oz.,  may  be  employed;  or  nitrate  of  silver  in  stick 
or  solution,  particularly  if  there  are  deep  cracks.  Van 
Harlingen  speaks  well  of  the  following: 

1$ — Acidi  phosphoric!  dil., 

Glycerin!, 

Syrup! aa     3ss — M. 

S. — Apply  t.  i.  d. 

Shoemaker's  method  of  immobilizing  the  lips  with  adhe- 
sive plaster  is  an  excellent  one.  The  diachylon  plaster 
mull  may  be  used  for  the  same  purpose. 

If  silver  nitrate  has  been  employed,  it  is  well  to  paint  the 
parts  afterward  with  compound  tincture  of  benzoin.  Paint- 
ing with  flexible  collodion  will  often  afford  relief. 

A  careful  investigation  of  the  patient's  general  health 
will  sometimes  discover  a  clue  as  to  the  cause  of  this  intract- 
able affection,  ~nd  its  removal  will  result  in  the  disappear- 
ance of  the  local  disorder.  It  has  been  pointed  out  (Neisser) 
that  certain  tooth  washes  or  pastes  sometimes  are  respon- 
sible for  the  condition. 

In  pustular  eczema  of  the  upper  lip,  any  nasal  discharge 
that  may  be  present  should  be  checked  as  quickly  as  pos- 
sible and,  in  the  adult,  the  vibrissee  should  be  removed. 
The  best  local  application  in  the  acute  stage  is  the  ungwn- 
tum  vaselini  plumbicum  combined  with  5  or  10  per  cent, 
xeroform.  In  more  chronic  conditions  a  modified  Rosen- 
thai  paste  acts  well : 

1$ — Acidi  tannici gr.  Ixxv 

Sulph.  pnpcip oijss 

Zinc!  oxidi, 

Pulv.  amyli aa  oiij 

Vaselini Sijss — M. 

S. — Smear  on  thinly  twice  a  day. 

If  the  infiltration  is  excessive  it  will  be  found  necessary 
to  exert  pressure  by  means  of  a  bandage,  and  to  do  this 


ECZEMA  105 

effectually  a  thin  wedge  of  cork  should  be  worn  between  the 
lip  and  the  teeth. 

Eczema  of  the  Lids. — This  is  a  rather  frequent  form  of 
eczema,  especially  in  connection  with  the  same  affection 
occurring  on  the  face  generally.  Eczema  of  the  edges  of 
the  lids  is  especially  frequent  in  strumous  children  and 
may  be  associated  with  a  chronic  conjunctivitis.  Eczema 
tarsi  is  in  the  great  majority  of  cases  associated  with  a 
seborrhea  of  the  scalp  and  probably  owes  its  origin  to  that 
source.  Many  cases  of  styes  have  undoubtedly  the  same 
etiology.  Moist  eczema  of  these  parts  is  by  no  means 
uncommon. 

Treatment. — The  most  soothing  applications  are  de- 
manded for  eczema  of  the  general  surface  of  the  lids, 
even  if  there  be  considerable  thickening.  Equal  parts 
of  cold  cream  and  zinc  salve  will  be  found  agreeable. 
Jamieson's  ophthalmic  salve  is  useful : 

1$ — Olei  amygdalae  dulcis, 

Aquae  destillatss aa     5ss 

Lanolini 3iij — M. 

Equal  parts  of  cold  cream  and  lanolin  serve  a  good  pur- 
pose. If  the  disease  involves  the  edge  of  the  lids,  epilation 
of  the  lashes  is  often  demanded,  although  the  use  of  the 
following  may  render  this  procedure  unnecessary: 

1^ — Hydrarg.  oxidi  flav gr.  ij-viij 

Vaselini 5j — M. 

S. — Apply  to  edges  of  lids  with  a  camel's-hair  pencil. 

The  adjustment  of  proper  glasses  may  do  much  good,  as 
some  ocular  defect  may  be  the  origin  of  the  trouble.  Many 
of  these  cases  of  eczema  tarsi  come  as  sequels  to  the 
eruptive  fevers,  and  demand  tonic  treatment. 

In  every  case  the  condition  of  the  scalp  should  be  looked 
to,  and  if  marked  seborrhea  is  present  it  should  be  removed. 
The  head  should  be  shampooed  at  least  once  a  week  with 
the  green  soap  preparation,  the  patient  meanwhile  rubbing 
in  the  following:  • 


106  INFLAMMATIONS 

f$ — Acidi  salicylic! 9j 

Sulph.  prsecip 5jj 

Vaselim 3j — M. 

S. — Apply  once  a  day. 

In  strumous  children  cod-liver  oil  and  iron  are  demanded. 

Eczema  of  the  Beard. — The  symptoms  of  this  form  are 
similar  to  those  observed  in  eczema  of  the  scalp;  any  of 
the  elementary  lesions  may  be  present.  Most  cases  are, 
however,  of  the  pustular  type.  The  affection  may  involve 
limited  regions  only,  or  may  extend  to  the  entire  beard,  and 
even  to  the  eyebrows  and  eyelashes.  It  is  not  necessarily 
confined  to  the  hairy  region,  as  it  at  times  invades  the 
neighboring  glabrous  skin,  thus  differing  from  sycosis, 
which  it  may  resemble  somewhat  in  other  respects.  Pus- 
tular eczema  of  the  beard  may  be  either  acute  or  chronic. 
In  the  acute  form  the  parts  are  hot,  swollen,  and  tender, 
and  upon  the  congested  skin  small  pustules,  which  are 
seated  between  the  hairs  and  at  the  follicle  mouths,  appear 
in  great  numbers.  These  soon  rupture,  the  purulent  dis- 
charge drying  to  yellowish  or  greenish  crusts  that  mat  the 
hairs  together.  In  the  chronic  type,  the  hairs  become 
somewhat  thinned,  and  removal  of  the  crusts  shows  a 
reddened,  exuding  surface,  which  is  usually  smooth ,  and 
not  tuberculated  as  in  sycosis.  A  squamous  form  at  times 
follows  in  the  wake  of  the  other  varieties  and  is  apt  to  be 
obstinate.  It  usually  occurs  in  circumscribed  patches 
attended  with  much  pruritus. 

Treatment. — In  the  acute  cases  soothing  treatment  is 
indicated.  The  beard  should  be  closely  clipped  and  appli- 
cations of  salicylated  or  carbolized  oil ;  olive  oil  and  lime- 
water,  equal  parts;  black  wash,  cold  cream,  etc.,  made 
to  the  affected  region.  Frequent  shaving  is  imperative 
after  the  subacute  stage  has  been  reached,  though  the 
patient  and  the  barber  are  apt  to  declare  this  impossible. 
However,  it  can  and  should  be  done  every  second  day  at 
least,  and  may  be  followed  by  an  application  of  unguentum 
vaselini  plumbicum  on  muslin.  Such  hairs  as  are  situ- 
ated in  pustules  should  be  epilated  before  shaving.  If  the 


ECZEMA  107 

condition  has  become  chronic,  more  active  measures  are 
demanded.  The  remedy  that  we  have  found  most  useful 
in  this  disease  and  also  in  coccogenic  sycosis  is  Rosenthal's 
paste.  (See  formula  under  Pustular  Eczema  of  the  Lips.) 
Robinson's  ointment  is  valuable: 

1$ — Ung.  diachylon, 

Ung.  zinci  oxidi aa  5ss 

Ung.  hydrarg.  ammon 3jij 

Bismuthi  subnit 5jss — M. 

This  also  serves  a  good  purpose: 

1$ — Sulphuris  praccip 3j 

Ung.  aq.  rosse 5j — M.  - 

Lassar's  paste  or  the  following  may  also  be  tried : 

1$ — Hydrarg.  ammoniati 9j 

Liq.  carbonis  detergentis 3ss 

Vaselini 5j — M. 

Another  tar  preparation  is  as  follows : 

1$ — Olei  rusci 3j 

Ung.  aq.  rosse 5j — M. 

The  tar  preparations  are  particularly  beneficial  in 
squamous  forms  of  eczema. 

The  disease  is  very  prone  to  relapse,  and  the  treatment 
should  be  kept  up  in  a  modified  way  long  after  it  is  appar- 
ently cured. 

When  the  disease  is  well  along  toward  recovery  the  salve 
may  be  kept  on  only  at  night,  a  dusting  powder  of  oleate  of 
zinc  being  applied  during  the  day. 

Eczema  of  the  Breast  and  Nipple. — This  form  is  most 
commonly  met  with  in  nursing  women,  although  virgins 
and  even  males  are  not  altogether  exempt.  In  the  mild 
type  one  or  both  nipples  are  attacked,  presenting  a  super- 
ficial denudation  of  epithelium  with  slight  discharge  and 
crust  formation  if  the  parts  are  at  rest.  In  more  severe 
cases  the  nipple  is  raw,  swollen,  and  deeply  fissured;  some- 
times it  is  sunken  below  the  surrounding  areola,  which 
latter  is  heavily  crusted  with  the  inspissated  discharge. 
The  eruption  is  usually  in  the  form  of  a  circle  about  the 


108  INFLAMMATIONS 

nipple  and  may  extend  to  involvement  of  the  entire  breast 
and  perhaps  to  the  trunk.  Mastitis  is  not  an  infrequent 
sequela.  Eczema  intertrigo  frequently  attacks  the  under 
surfaces  of  the  breasts  in  obese  women. 

Treatment. — For  fissured  nipples,  Veiel  recommends 
Lister's  formula: 

1^ — Acidi  boracici, 

Cerse  albae aa     gr.  xv 

Paraffin, 

Olei  amygdalae aa     3ss — M 

S. — Wash  the  nipple  after  nursing  with  borax  water  (1  to  25), 
then  apply  salve  on  muslin. 

For  the  acute  form  of  the  disease  the  modified  diachylon 
ointment,  or  Unna's  paste,  answers  well: 

1$ — Sacchari  albi, 

Zinci  oxidi, 

Mucilag.  acacise, 

Glycerini aa     oj — M. 

S. — Apply  after  drying  parts  thoroughly. 

Many  procedures  have  been  suggested,  all  testifying  to 
the  obstinate  nature  of  the  disease,  thus,  tinctures  of  myrrh 
and  benzoin,  the  silver  nitrate  crayon,  weak  solutions  of 
the  same  salt  (16  gr.  to  1  oz.),  lead  and  rubber  shields,  etc., 
have  each  been  highly  praised.  In  non-nursing  women, 
green  soap  friction  followed  by  unguentum  vaselini 
plumbicum  is  one  of  the  best  methods.  Lassar's  paste  is 
valuable  in  eczema  intertrigo.  Liveing  highly  praises  the 
silver  nitrate  solution.  We  prefer  it  made  thus: 

1$ — Argenti  nitratis gr.  xvj 

Spiritus  setheris  nitrosi §j — M. 

S. — Brush  over  affected  surface. 

Eczema  of  the  Umbilicus. — In  this  location  the  disease 
generally  assumes  the  form  of  an  eczema  rubrum,  and  is 
usually  excited  by  seborrhea  of  the  part.  The  navel  is  red 
and  swollen,  more  or  less  crusted,  with  a  rather  offensive 
exudation.  At  times  the  neighboring  skin  is  involved. 

Treatment. — Eczema  of  the  umbilicus  is  frequently  quite 
resistant  to  treatment.  Duhring  suggests  this  formula: 


ECZEMA  109 

PJ — Zinci  oleatis oj 

Hydrarg.  chloridi  mitis  ......      gr.  xv-xxx 

Vaselini 5j — M. 

Boric  salve  used  as  in  eczema  of  the  nipple  is  also  of 
value.  Salicylic  acid,  sulphur,  or  weak  preparations  of 
resorcin,  in  ointment  form,  may  be  tried.  It  is  well  to 
apply  the  salve  on  lint  and  insert  this  into  the  navel. 

Eczema  of  the  Flexor  Surfaces  or  the  Joints.— Eczema 
in  these  localities  is  usually  symmetrical  and  is  apt  to 
assume  the  appearance  of  an  eczema  intertrigo,  though 
the  skin  may  become  much  infiltrated,  fissured,  and  covered 
with  scales. 

Treatment. — In  the  acute  stage  Lassar's  paste  or  Fox's 
modification  of  it  is  very  efficient.  In  the  subacute  condi- 
tions the  tar  and  zinc  salve  may  be  employed  to  advantage : 

1$ — Zinci  oxidi 5j 

Ung.  picis  liq 5ij 

Ung.  aq.  rosae, 

Lanolini aa  3iv — M. 

Or,  the  compound  salicylic  plaster.  If  the  disease  has 
become  chronic,  frictions  of  green  soap,  followed  by  tar 
salve  or  the  unguentum  vaselini  plumbicum,  should  be 
employed. 

Eczema  Intertrigo. — This  occurs  between  the  gluteal 
folds,  in  the  axillae  and  groins,  under  the  breasts  of  women 
and,  in  fact,  wherever  two  surfaces  of  skin  come  in  close 
contact.  It  usually  has  its  beginning  in  a  simple  erythema 
intertrigo  that  has  gone  untreated.  In  order  to  avoid  this 
condition  stout  people  especially  should  keep  the  parts 
freely  dusted  with  some  bland  powder. 

Treatment. — When  the  disease  is  once  established,  the 
affected  surfaces  should  receive  few  ablutions  and  should 
be  kept  separated  by  a  thin  layer  of  lint. 

Dusting  powders  are  of  advantage: 

1^ — Thvmolis gr.  j 

1'ulv.  zinci  oleatis 3j — M. 

1$ — Pulv.  sem.  lycopodii oij 

Zinci  oxidi ovj — M. 


110  INFLAMMATIONS 

Lassar's  paste  is  useful;  and  in  certain  cases  a  salve  of 
boric  acid  (1  drachm  to  1  oz.),  or  of  salicylic  acid  (15  gr.  to 
1  oz.)  may  be  tried.1 

Eczema  of  the  Anus  and  Perineum. — The  disease  in 
this  region  is  not  often  acute  in  character.  The  anus  alone 
may  be  affected,  or  the  perineum  and  scrotum  may  also  be 
attacked.  The  mucocutaneous  folds  may  be  congested, 
slightly  thickened,  and  with  or  without  fissures.  In  most 
instances  the  discharge  is  free  and  very  offensive.  In  more 
severe  cases  the  parts  are  red,  greatly  thickened,  exhibit 
painful  cracks,  and  the  eczema  extends  up  to  the  anal 
mucosa  and  may  actually  involve  it.  One  of  the  most 
painful  manifestations  is  the  implication  of  the  raphe. 
The  disease  is  accompanied  by  intolerable  pruritus,  which 
is  usually  worse  at  night,  and  pain  is  often  severe  as  a  result 
of  the  fissures  and  the  rawness  left  from  scratching. 

The  skin,  in  long-standing  cases,  may  assume  the  ap- 
pearance of  "white  parchment."  Hemorrhoids,  catarrhal 
inflammations,  and  prolapse  of  the  rectum  are  frequent 
complications  or  etiological  factors  in  this  disease. 

Treatment. — The  internal  treatment  is  very  important. 
The  diet  should  be  regulated  carefully,  smoking  forbidden, 
and  a  regular  movement  of  the  bowels  maintained.  For 
the  latter  purpose  Bulkley  recommends  this  formula : 

1$ — Sulph.  prsecipitat., 

Potass,  bitartrat aa     5j — M. 

S. — 1  to  2  drachms  at  night  in  water. 

Compound  liquorice  powder  is  serviceable  also.  Any 
complicating  rectal  disorder  should  be  removed  and 
gouty  and  lithemic  states,  if  present,  should  receive 
appropriate  treatment.  Bulkley's  method  of  using  hot 
water  is  of  great  value  and  nothing,  probably,  relieves 
so  much  the  distressing  pruritus.  Before  beginning  the 
fomentations  the  following  salve  should  be  spread  on  a 
suitable  piece  of  lint: 

1  See  also  under  Erythema. 


ECZEMA  HI 

1$ — Zinci  oxidi 3j 

Pulv.  amyli 5ij 

Ung.  picis  liq 3ij-iv 

Ung.  vaselini  plumbici       .      .      .      q.  s.  ad  §j — M. 

The  patient  then  sits  upon  a  low  chair,  having  a  pan  of 
very  hot  water  between  his  feet.  Into  this  he  dips  a  soft 
cloth  which  is  immediately  withdrawn  and  pressed  firmly 
against  the  affected  region  for  the  space  of  a  minute.  This 
process  is  repeated  three  times,  when  the  parts  should  be 
quickly  dried  and  the  ointment  applied  immediately.  The 
fomentations  may  be  repeated  on  the  following  morning, 
if  desired,  but  usually  a  reapplication  of  the  ointment 
alone  will  suffice  at  that  time. 

Much  relief  is  occasionally  afforded  by  mild  mercurial 
and  carbolic  salves.  1  drachm  of  calomel  to  1  oz.  of  vas- 
elin  is  often  serviceable.  Liveing  praises  the  following: 

1$ — Bismuthi  nitratis 3ij 

Morphin.  hydrochlorat gr.  ij 

Ung.  aq.  rosae 5j — M. 

The  nitrate  of  silver  solution  is  valuable  at  times : 

1$ — Argenti  nitrat gr.  xv 

Spiritus  setheris  nitrosi 5j— M. 

S. — Paint  on  parts. 

Lassar's  paste  is  a  good  application,  as  is  also  the 
following: 

1$ — Acidi  carbolici n\x-xv 

Zinci  oxidi 3j 

Bismuthi  subnit 5ss 

Pulveris  amyli 3ij 

Vaselini 5j — M. 

Duhring  recommends  the  following  as  worthy  of  trial : 

1} — Sulph.  prsecipitati 9ij 

Naphthol 9j 

Morphin.  sulphatis gr.  ij 

Zinci  carbonatis 5j 

Ung.  aq.  rosie 5j — M. 

The  stronger  remedies,  as  silver  nitrate,  potash,  and 
coal-tar,  should  be  reserved  for  cases  showing  much  infil- 


112  INFLAMMATIONS 

tration.    Scarifications   will    cure   some   rebellious  cases. 
(See  treatment  by  x-ray.) 

Eczema  of  the  Genitals. — Eczema  of  the  scrotum,  of 
the  erythematous  and  weeping  forms,  are  fairly  frequent, 
beginning  as  a  rule  insidiously  and  leading  to  leathery, 
infiltrated  skin,  with  exaggeration  of  the  natural  furrows. 
There  may  be  much  swelling,  and  an  offensive,  gummy 
secretion  is  poured  out  in  the  moist  variety.  In  the  ery- 
thematous and  squamous  cases  hard  nodules  may  form 
which  later  suppurate  and  cause  no  little  annoyance. 

Eczema  occurring  on  the  penis  is  mostly  erythematous 
in  character  and  usually  attacks  that  portion  of  the  organ 
which  is  in  contact  with  the  scrotum,  though  the  whole  or 
any  portion  of  it  may  be  involved.  In  general  involvement 
of  the  penis  the  whole  member  may  be  enormously  in- 
creased both  in  length  and  breadth.  A  condition  of  ele- 
phantiasis may  be  brought  about,  as  in  a  case  under  our 
care,  necessitating  the  removal  of  the  prepuce. 

In  women  the  labia  majora  are  frequently  the  sites  of  a 
vesicular  eczema  that  is  attended  by  much  swelling,  and 
that  rapidly  becomes  an  eczema  rubrum.  However,  any 
form  of  the  malady  may  attack  the  female  genitalia,  and 
the  eruption  may  extend  to  the  clitoris,  nymphse,  or  into  the 
vagina.  In  these  cases  the  parts  are  raw,  swollen,  and 
moist,  with  intolerable  itching. 

In  either  sex  the  eruption  may  be  limited  to  the  genitals 
or  may  spread  to  the  mons  veneris,  abdomen,  or  thighs. 
In  all  obstinate  eczemas  of  these  parts  the  urine  should  be 
examined  for  sugar,  and  the  possibility  of  the  presence  of 
pediculi  be  borne  in  mind.  In  women  a  leucorrheal  dis- 
charge or  some  less  apparent  pathological  condition  of  the 
genital  tract  may  be  responsible  for  the  trouble. 

Treatment. — In  acute  eczema  of  the  penis  and  scrotum, 
soothing  measures,  as  the  calamine  and  zinc  lotion,  or 
the  oxide-of-zinc  emulsion  with  almond  oil,  should  be  used. 
Eczema  of  the  prepuce  responds,  as  a  rule,  to  Lassar's 
paste.  The  subacute  forms  involving  the  scrotum  or 
labia  do  well  under  the  tar  and  zinc  salve;  and,  if  the  itch- 


ECZEMA  113 

ing  be  intense,  Bulkley's  hot-water  method  is  of  great  value. 
The  unguentum  vaselini  plumbicum  alone  may  do  much 
to  better  the  condition.  These  various  dressings  are  to  be 
held  in  place  by  a  suitable  suspensory  in  men,  and  in  case 
of  women  by  a  T-bandage. 

In  the  chronic  infiltrated  type,  occurring  on  the  scrotum, 
stimulation  is  demanded.  A  good  method  is  to  rub  the 
part  with  a  solution  of  salicylic  acid  in  alcohol  (1  drachm  to 
4  oz.),  and  afterward  apply  the  unguentum  vaselini  plumbi- 
cum, with  1  drachm  of  boric  acid  to  1  oz.  Green  soap  fric- 
tions followed  by  the  same  salve  oftentimes  does  much  good 
in  rebellious  cases.  The  compound  5  per  cent,  salicylic  acid 
plaster  spread  on  muslin  and  bound  to  the  scrotum  may 
be  recommended.  Wilkinson's  salve  may  be  mentioned: 

1} — Olei  cadini, 

Sulph.  sublimat aa     3iv 

Saponis  viridis, 

Adipis aa     5j 

Crsetse  prsep 5ijss — M. 

Silver  nitrate  or  caustic  potash,  10  to  20  gr.  to  1  oz., 
used  as  a  paint,  is  sometimes  efficacious,  as  also  is  tinc- 
ture of  iodine,  or  Vleminckx's  solution,  pure  or  dilute. 
These  latter  are  to  be  rubbed  in.  Veiel  recommends  a 
tar-diachylon  salve  (1  to  20)  that  may  be  increased  gradu- 
ally to  1  to  2.  The  same  general  method  is  to  be  pursued 
in  case  of  chronic  vulvar  eczema,  although  the  preparations 
should  be  reduced  considerably  in  strength. 

Eczema  of  the  Hands  and  Feet. — Eczema  of  the  hands 
and  feet  is  quite  common.  The  hands  are  more  frequently 
involved,  though  all  four  members  may  be  affected  at  the 
same  time.  The  disease  is  usually  symmetrical.  The 
greater  frequency  on  the  hands  is  doubtless  due  to  their 
more  frequent  exposure  to  various  irritants.  The  dorsal 
surfaces  of  the  hands  and  feet  may  be  attacked  by  any 
form  of  the  disease,  particularly  papular,  squamous,  and 
moist  varieties;  and  eczema  intertrigo  is  not  uncommon 
between  the  fingers  and  toes.  Acute  vesicular  eczema  is 
comparatively  frequent,  especially  on  the  hand,  the  whole 


114  INFLAMMATIONS 

member  being  covered  with  a  multitude  of  minute  vesicles. 
On  the  palmar  surface,  owing  to  the  thick  epidermis,  the 
vesicles  do  not  burst  readily  and  they  may  burrow  for  a 
considerable  distance. 

All  degrees  of  the  dry,  squamous  eczema,  aptly  called 
eczema  rimosum,  may  be  found  on  the  palms  and  soles. 
At  times  the  condition  is  merely  one  of  excessive  dryness 
with  moderate  infiltration;  again  there  are  well-defined 
fissured  and  thickened  patches  occupying  the  centre  of  the 
hand ;  or,  perhaps,  they  may  be  more  pronounced  over  the 
thenar  and  hypothenar  eminences.  In  more  severe  cases 
the  whole  surface  may  be  involved  even  to  the  extent  of 
seriously  interfering  with  the  use  of  the  members.  The 
same  condition  may  be  found  limited  to  the  tips  of  the 
fingers.  Pruritus  is  usually  not  marked  in  dry  eczemas  of 
the  palms  and  soles  and  may  be  altogether  absent. 

In  these  cases,  owing  to  the  anatomical  arrangement  of 
the  parts,  and  to  the  inelasticity  of  the  infiltrated  skin, 
cracks  and  fissures  soon  form,  which  prove  very  painful. 
In  addition  to  the  squamous  eczema  of  the  soles,  any  form 
of  the  disease  may  occur  on  the  dorsi.  Papular  and  ery- 
thematous  eczema  is  common  on  the  instep  and  ankles, 
and  is  very  annoying. 

Treatment. — Nothing  succeeds  so  well  in  acute  vesicular 
eczema  of  the  hands  as  the  familiar  calamine  and  zinc 
lotion.  It  should  be  applied  on  cheese-cloth  strips  and 
renewed  frequently;  5  to  10  minims  of  carbolic  acid  may 
be  added  to  1  oz.  When  the  acute  stage  has  passed 
away,  the  following  salve  should  be  applied : 

1^ — Ung.  picis  liq 5jj 

Zinci  oxidi oj 

Ung.  aq.  rosae 5vj — M. 

Eczema  of  the  backs  of  the  hands  and  feet  must  be 
treated  according  to  the  character  of  the  lesions  and  the 
stage  at  which  the  disease  has  arrived.  Subacute  papular 
and  vesicopapular  conditions  are  benefited  by  the  fol- 
lowing: 


ECZEMA  115 

1$ — Bismuthi  subnit 3iv 

Zinci  oxidi 5j 

Pulv.  amyli 3ij 

Acidi  carbolic! rri_x-xv 

Vaselini 5j — M. 

Ointments  of  white  precipitate  (20  to  30  gr.  to  1  oz.)  or  of 
tar  and  zinc,  and  Lassar's  paste,  may  be  found  useful  in 
certain  cases.  Eczema  rubrum  often  requires  green  soap 
frictions,  followed  by  the  unguentum  vaselini  plumbicum. 
The  condition  between  the  toes  and  fingers  may  be  treated 
by  the  lead  ointment,  with  1  or  2  per  cent,  carbolic  acid  or 
in  some  cases  by  a  powder: 

1$ — Thymolis  gr.  j 

Pulv.  zinci  oleatis 5j — M. 

A  thick  paste  like  Lassar's  or  Inlets  or  paintings  with  sil- 
ver nitrate  (16  gr.  to  1  oz.)  may  occasionally  be  demanded. 

If  there  is  great  thickening  it  must  be  got  rid  of,  and  this 
is,  perhaps,  best  accomplished  by  means  of  Unna's  salicylic 
acid  plaster  mull  (15  to  20  per  cent.),  or  a  salicylic  collodion 
(^  drachm  to  1  oz.).  Duhring's  compound  salicylic  acid 
plaster  (10  per  cent.)  will  probably  do  as  well  (see  above). 
The  plaster  is  to  be  spread  on  muslin  and  held  in  place  by 
bandages  or  gloves.  Occasionally  it  may  be  necessary  to 
blister  with  cantharidal  collodion  or  to  rub  in  a  solution  of 
caustic  potash.  The  preparation  known  as  "  Emol  Keleet," 
a  natural  product  similar  to  fuller's  earth,  has  marked 
softening  properties.  It  may  be  used  in  the  following 
formula: 

1^— Emol  keleet 3ij 

Zinci  oxidi 3j 

Glycerinse  plumbi  subacetatis,  B.  P.        .  q.  s. 

Lanolini, 

Vaselini aa     5ss — M. 

S. — Apply  at  night  and  cover  the  hands  with  lint. 

Use  sufficient  glycerin  of  the  subacetate  of  lead  to  con- 
vert the  powders  into  a  paste;  then  mix  with  the  vaselin 
and  lanolin.  After  the  thickened  epidermis  has  been  re- 
moved, rub  into  the  patches  twice  a  day  the  following: 


116  INFLAMMATIONS 

]$ — Ol.  rusci 5j 

Ung.  aq.  rosse 5j — M. 

Eczema  of  the  feet  in  its  manifold  expressions  should  be 
treated  upon  the  same  general  principles.  In  all  forms  of 
eczema  of  these  members,  or  of  the  hands,  freedom  of  the 
parts  from  irritating  influences  is  a  very  essential  part  of 
the  treatment.  If  the  calling  of  the  individual  is  respon- 
sible for  the  condition,  it  may  be  necessary  for  him  to  give 
it  up,  at  least  for  a  time. 

In  many  cases,  however,  it  is  impossible  for  the  patient 
to  relinquish  his  work,  and  under  these  circumstances  the 
physician  may  direct  him  to  follow  the  method  recom- 
mended by  Unna.1 

At  night  the  patient  should  wash  his  hands  first  with  oil 
and  then  with  soap  and  water;  afterward  the  hands  are 
dressed  with  strips  of  cotton  cloth  which  have  been  spread 
with  oil  or  some  suitable  ointment.  In  the  morning  this 
is  removed  with  dry  wool,  and  the  parts  are  rubbed  with 
the  salve  stick,  which  is  a  mixture  of  wax  and  lanolin  and 
not  easily  saponified  by  alkalies.  Walker's  formula  for  the 
salve  stick  is  cocoa  butter,  2  parts;  wax,  1  part;  lanolin, 
^  part.  This  salve  stick  may  be  rubbed  over  the  hands 
several  times  a  day.  After  work  the  hands  should  be 
cleaned  with  oily  wool,  washing  with  soap  and  water  being 
limited  to  once  a  day.  The  modified  diachylon  ointment 
(unguentum  vaselini  plumbicum)  is  perhaps  the  best  salve 
for  the  application  at  night,  and  the  soap  known  as  "  Emol 
Keleet,"  when  procurable,  is  the  blandest  of  articles.  The 
ar-ray  is  a  valuable  method  of  treatment  in  infiltrated 
patches  (vide  infra). 

Eczema  of  the  Nails. — Eczema  may  attack  the  nails 
without  being  present  in  other  situations,  but  as  a  rule  the 
hands  or  feet  are  also  affected.  The  nail  is  rough  and 
uneven,  and  lacks  its  normal  luster.  It  is  usually  quite 
brittle  and  breaks  readily.  The  skin  around  the  base  and 
sides  may  become  thickened,  red,  and  itchy.  The  nails 

1  Quoted  by  Norman  Walker. 


ECZEMA 

often  show  striations  and  furrows,  and  hypertrophy  of  the 
subungual  portion  of  the  epidermis  may  lift  the  nail  up 
from  its  bed  for  a  considerable  distance. 

Arsenic  given  over  long  periods  in  moderate  doses  is  of 
undoubted  value  in  these  cases.  The  various  combina- 
tions of  salicylic  acid,  tar,  and  mercury,  may  be  tried  locally. 
Shoemaker  recommends  an  ointment  of  tin  oleate.  For 
the  removal  of  hyperkeratotic  subungual  tissue,  a  salicylic 
acid  paste,  or,  as  suggested  by  Hebra,  its  destruction  with 
the  Paquelin  cautery,  may  be  employed.  Salicylic  acid 
collodion  may  be  painted  on  the  infiltrated  integument 
around  the  borders  of  the  affected  nail.  Applications  of 
the  a>ray  often  produce  surprising  results. 

Eczema  of  the  Legs. — The  disease  in  this  situation  is 
of  rare  occurrence  in  children,  adults  being  much  more 
frequently  affected,  especially  those  who  are  obliged  to 
spend  a  large  portion  of  the  time  on  their  feet. 

Any  of  the  types  may  be  encountered  here,  the  most 
striking  and  common  form  being  eczema  rubrum.  When 
fully  developed,  this  latter  constitutes  a  picture  not  easily 
forgotten. 

The  disease  may  develop  in  single  patches  that  remain 
separate,  or  they  may  coalesce  to  form  a  large  sheet  that 
may  cover  the  anterior  surface  or  indeed  the  entire  leg. 
Its  extent  is  usually  limited  by  the  knee  above  and  the 
ankle  below,  but  it  may,  at  times,  overstep  either  boundary, 
going  a  variable  distance  in  either  direction.  When  first 
seen  by  the  physician  the  disease  is  usually  chronic,  and 
if  it  has  not  been  treated  presents  a  deep-red,  raw,  and 
exuding  skin,  with  here  and  there  evidences  of  scratching. 
Scattered  over  the  surface  are  variously  sized  yellowish, 
brownish,  or  blackish  crusts.  Sometimes  the  legs  ;uv 
purplish  red,  tense,  and  shining,  with  no  trace  of  scales  or 
crusts.  Varicose  veins  and  ulcers  are  the  usual  accom- 
paniments of  this  disease,  and  are  undoubted  etiological 
factors  in  these  cases.  Infiltration,  exudation,  and  severe 
itching  are  prominent  symptoms,  and  there  is  frequently, 
in  the  varicose  condition,  much  pain  of  a  deep,  boring  char- 


118  I  NFL  AM  MA  TIONS 

acter.  Various  hypertrophic  changes  follow  in  the  wake  of 
long-continued  eczema  of  the  legs.  Marked  and  enduring 
pigmentation  is  usual  after  healing. 

Treatment. — If  the  case  should  be  seen  in  the  acute  stage 
White's  plan  of  mopping  on  black  wash  every  few  hours, 
followed  by  zinc  ointment  or  cold  cream  with  zinc,  is  a 
good  method. 

In  classical  eczema  rubrum  of  the  leg,  nothing  gives  such 
excellent  results  as  Hebra's  green  soap  frictions  followed 
by  unguentum  vaselini  plumbicum. 

The  following  directions  should  be  closely  followed : 

In  the  first  place,  before  beginning  the  soaping,  the  lead 
salve  should  be  evenly  spread  on  strips  of  muslin  and  put 
aside  in  a  convenient  place;  the  next  step  is  to  dip  a  piece 
of  flannel  into  lukewarm  water,  and,  having  wrung  it 
nearly  dry,  to  smear  on  it  a  piece  of  the  green  soap  of  the 
size  of  a  hickory  nut.  The  soap  should  now  be  firmly 
rubbed  into  the  affected  parts  for  a  few  minutes,  and  when 
this  has  been  accomplished,  the  flannel  should  be  dipped 
into  the  water  again,  and  while  still  wet  briskly  rubbed  over 
the  surface  once  more.  As  soon  as  this  process  has  been 
concluded,  the  lather  should  be  washed  off,  the  skin  gently 
dried,  and  the  prepared  muslin  evenly  and  neatly  applied, 
and  the  dressing  kept  in  place  with  a  roller  bandage. 
According  to  circumstances,  the  soap  frictions  may  last 
from  five  to  twenty  minutes,  and  be  repeated  once  or  twice 
a  day.  After  the  first  rubbings  the  skin  will  look  very 
angry,  but  after  a  time  the  itching  diminishes,  the  infiltra- 
tion disappears,  and  the  surface  gradually  assumes  its 
normal  appearance. 

In  other  cases,  especially  when  the  exudation  and 
crusting  is  moderate,  the  glycerin  jelly  is  a  good  appli- 
cation (see  formula  on  page  115);  or  this  formula  of 
Morrow's  may  be  tried:  Add  250  parts  of  glycerin  to  1000 
of  gelatin  and  2000  of  water,  and  with  this  combine  10 
per  cent,  of  zinc  oxide  and  1  per  cent,  of  carbolic  acid. 
Duhring  and  Van  Harlingen  speak  well  of  Squire's  glycerole 
of  the  subacetate  of  lead  in  the  strength  of  15  to  30  gr.  to 


ECZEMA  119 

1  oz.  of  glycerin.  Strips  of  linen  are  soaked  in  this, 
and  after  application  to  the  legs  are  covered  with  waxed 
paper  and  bandaged.  Unna's  paste  is  also  useful: 

1$ — Kaolini, 

Ol.  lini aa     3vj 

Zinci  oxidi, 

Liq.  plumbi  subacetatis aa     5ss — M. 

S. — Apply  with  a  brush  and  then  bandage. 

The  elastic  web  bandage  is  a  valuable  adjunct  when  there 
are  varicose  vessels  or  ulcers.  It  is  greatly  superior  to  the 
elastic  stocking,  as  pressure  can  be  varied  at  will  and  can 
at  all  times  be  kept  uniform.  The  stockings  soon  stretch 
and  become  worthless.  The  bandage  should  in  no  case  be 
applied  directly  to  the  skin.  On  the  contrary,  the  local 
application  of  whatever  sort,  should  first  be  applied;  if  a 
salve,  on  strips  of  muslin.  A  light  muslin  or  gauze  bandage 
is  thrown  over  this  and  then  a  long,  white  cotton  stocking 
is  drawn  on.  The  elastic  bandage  is  finally  placed  over  all, 
care  being  taken  to  obtain  an  equable  pressure.  It  is  a 
good  plan  to  keep  the  parts  of  the  leg  not  covered  by  salve 
well  dredged  with  a  dusting  powder.  Such  a  bandage 
should  be  applied  always  before  getting  out  of  bed  in  the 
morning  and  removed  only  after  assuming  the  horizontal 
position  at  night.  As  a  prophylactic  measure  the  bandage 
should  be  worn  even  after  the  skin  has  healed.  Pick, 
Klotz,  and  Duhring  speak  highly  of  the  various  salicylated 
soap  plasters  and  they  are  doubtless  often  of  benefit, 
though  we  think  they  are  best  adapted  to  the  scaly  and 
hypertrophic  conditions. 

Universal  Eczema. — The  disease  rarely  covers  the  whole 
body,  there  being  usually  more  or  less  uninvolved  skin. 
Any  type  of  the  disease  may  become  universal,  or  several 
types  may  coexist.  A  form  of  diffuse  eczema  that  is  fairly 
common  in  elderly  people  consists  of  an  eruption  of  closely 
set  papules  about  the  forehead,  cheeks,  back  of  the  neck, 
arms,  and  thighs.  The  papules  run  together,  forming 
infiltrated,  scaling,  and  fissured  patches  that  are  intolerably 
itchy. 


120  INFLAMMATIONS 

Treatment. — Patients  suffering  from  universal  eczema, 
especially  the  aged,  should  be  put  to  bed  and  kept  as  quiet 
as  possible.  Such  constitutional  treatment  should  be 
undertaken  as  the  case  would  seem  to  warrant.  In  the 
dry  forms  of  the  disease,  powders  and  lotions  serve  best. 
The  former  should  contain  usually  a  little  camphor  or 
carbolic  acid.  If  the  eczema  is  moist  and  the  symptoms 
acute,  the  common  carron  oil,  to  which  has  been  added 
1  minim  of  creosote  to  1  oz.,  is  a  very  soothing  appli- 
cation, or  a  liniment  containing  oxide  of  zinc  and  calamine. 
The  following  cream  suggested  by  Mclntosh  is  good : 


$ — Bismuthi  subnitrat. 
Zinci  oxidi 
Glycerin! 
Acidi  carbolici 
Vaselini 


oss 
ojss 

TT[XX-XXX 

3vj-M. 


S. — Apply  with  a  brush. 

For  universal  application  the  amount  of  carbolic  acid 
may  be  decreased  or  it  may  be  omitted  altogether. 

The  papular  form  mentioned  above  is  particularly 
obstinate.  Relief  from  the  itching  may  be  secured  by  the 
free  use  of  carbolic  acid  in  lotion  or  in  spray  form. 

The  following  serves  a  good  purpose : 

1$ — Mentholis 3ij 

Alcoholis q.  s. 

Acidi  carbolici 5ss 

Lotionis  zinci  oxidi  comp 5vj — M. 

Infiltrated  patches  may  be  treated  by  painting  on  this 
pigment : 

1$ — Acidi  salicylici gr.  xxiv 

Chrysarobini gr.  xxiv 

Traumaticini Bj — M. 

Wilkinson's  ointment  (see  above)  or  lotions  of  sulphate 
of  zinc  (4  drachms  to  1  pt.),  grindelia  robusta  (2  drachms 
to  8  oz.),  and  the  following  are  also  useful: 

1^ — Liquor  carbonis  detergentis, 

Liquor  plumbi  subacetatis       .      .      .      .  aa     oij 
Aquae  destillatse Sviij — M. 


ECZEMA  121 

Eczema  Infantile. — Most  works  on  dermatology  devote 
considerable  space  to  a  special  consideration  of  eczema  as 
it  occurs  in  infancy  and  childhood,  but  as  the  disease  varies 
but  little  in  its  clinical  expressions  at  any  age,  and  as  we 
have  endeavored  to  point  out  such  divergences  as  do 
exist  in  the  foregoing  sections,  we  shall  content  ourselves 
with  making  a  few  practical  statements.  In  the  first  place 
as  regards  prophylaxis.  Many  mothers  in  their  eagerness 
to  remove  the  sebaceous  secretions  from  the  scalps  of 
young  children  use  harsh  measures,  such  as  combing, 
scrubbing,  etc.,  for  the  purpose,  with  the  result  very  fre- 
quently of  setting  up  an  eczema  that  may  extend  down  on 
the  face  and  prove  very  rebellious  to  treatment.  This 
condition  generally  rights  itself;  or  in  obstinate  cases  dis- 
appearance of  the  unsightly  secretion  may  be  expedited  by 
inunctions  with  sweet  oil  or  vaselin. 

In  the  second  place,  more  particularly,  it  is  true,  in  dis- 
pensary practice,  very  young  infants  are  allowed  to  eat 
everything  that  is  going,  and,  besides,  to  drink  tea,  coffee, 
and  beer.  This,  of  course,  must  be  stopped,  and  the  child 
put  upon  food  suitable  to  its  age.  The  irritation  of  teething 
undoubtedly  has  an  effect  in  evoking  an  eczema,  as  indeed 
do  other  irritants  and  irritating  agencies,  but  the  comfort- 
able assurance  often  given  by  physicians,  that  the  eczema 
will  surely  disappear  when  dentition  has  been  completed,  is 
not  borne  out  by  experience.  Fox  and  others  call  attention 
to  the  fact  that  an  adherent  prepuce  is  often  responsible 
for  eczemas  in  children,  by  reflex  irritation.  The  great 
lesson  to  learn  in  all  eczemas,  and  in  eczema  at  all  ages,  is 
that  when  the  disease  goes  untreated  it  not  only  does  not 
tend  to  get  well,  but  that  something  closely  akin  to  an 
infectious  process  exists,  and  that  a  localized  patch  may  at 
any  time  be  the  focus  from  which  an  extension  of  the  dis- 
order may  be  expected.  Infants  and  children  should  be 
bathed  with  bland  soaps.  The  excretions  in  very  young 
children  should  receive  special  attention,  and  apposed 
surfaces  should  be  kept  dry  and  well  powdered.  It  is 
probably  a  fact  that  spoon-fed  infants  are  more  susceptible 


1 22  IN  FLAM  MA  TIONS 

of  eczema  than  those  nursed  by  their  mothers,  since  they  are 
prone  to  indigestions,  but  it  must  be  remembered  that  this 
is  only  one  of  many  possible  causes  of  the  affection.  There 
is  no  special  internal  treatment  for  infantile  eczema,  that 
is,  from  the  standpoint  of  the  dermatologist.  We  may  say, 
in  a  general  way,  that  iron  and  cod-liver  oil  are  very  valu- 
able in  suitable  cases.  The  local  treatment  we  have  already 
sufficiently  outlined.  We  may  here  repeat  the  caution  that 
eczema,  especially,  and  above  all  infantile  eczema,  must 
not  be  washed. 

The  X-ray  and  Other  Methods. — The  a:-rays  may  be 
advised,  by  way  of  exception,  in  certain  rebellious  chronic 
patches. 

Hahn  and  Albers-Schonberg  base  the  following  con- 
clusions on  the  treatment  of  14  cases: 

"In  a  weeping  eczema  the  exudation  disappears  after 
one  to  four  exposures,  and  does  not  return. 

"  In  pruriginous  eczema  the  itching  often  ceases  after  a 
single  application. 

"  In  dry  eczema  the  effect  of  the  rays  is  most  marked." 

These  opinions  are  confirmed  by  the  experiences  of 
Scholtz  and  of  Freund. 

We  have  been  successful  with  this  agent  in  certain  cases 
of  localized  infiltrated  eczema  in  which  no  other  treatment 
had  any  effect.  The  itching  is  generally  relieved  after  a 
few  sittings. 

The  x-rays,  according  to  Stelwagon,  occasionally  act 
admirably  in  thickened  palmar  cases,  and  are  sometimes 
serviceable  in  eczema  ani.  They  are  especially  useful  in 
eczema  of  the  nails. 

The  same  authority  advises  galvanism  in  localized  dense 
infiltrations  which  resist  absorption,  applying  the  negative 
electrode  with  5  to  20  ma.  In  the  same  cases  he  some- 
times uses  the  static  spark,  or  high-frequency  current.  The 
latter  is  especially  useful  in  subacute  and  chronic  forms 
for  the  relief  of  itching.  Allen  recommends  it  especially  in 
lesions  about  the  anus  and  genitals. 

Phototherapy  has  sometimes  done  well  in  cases  of  the 
same  sort. 


ECZEMA  123 

Prognosis. — The  prognosis  of  eczema,  as  regards  the 
cure  of  the  existing  eruption,  is  generally  good.  Like  all 
other  catarrhal  affections,  the  disease  is  apt  to  relapse 
whenever  the  exciting  cause  or  causes  come  into  operation. 
It  is,  therefore,  essential,  in  making  a  prognosis  either  as  to 
the  duration  of  a  present  manifestation  of  the  disorder,  or 
the  possibilities  of  a  relapse,  to  take  very  fully  into  con- 
sideration the  actual  condition  of  the  patient  at  the  time, 
and  also  his  constitutional  tendencies.  The  stage  of  the 
disease  and  its  location  must  also  necessarily  enter  into  the 
forecast.  An  acute  eczema,  if  promptly  and  properly 
treated,  is  manageable  enough,  but  if  allowed  to  become 
chronic,  with  the  consequent  more  or  less  profound  tissue 
changes,  the  difficulty  of  securing  relief  will  be  greater. 
For  anatomical  reasons,  an  eczema  on  the  hands  or  feet 
is  not  easy  to  manage,  especially  if,  in  addition  to  the 
difficulty  of  keeping  the  parts  at  rest,  the  patient  should 
follow  a  calling,  such  as  that  of  a  bricklayer,  washerwoman, 
etc.,  where  the  exciting  cause  is  always  in  operation.  Then, 
in  some  situations,  such  as  on  the  face,  the  subject  of  the 
disease  is  not  always  willing  to  apply  the  prescribed  reme- 
dies during  the  day,  thereby  losing  much  time,  and  in 
reality  undoing  in  one-half  of  the  twenty-four  hours  what 
had  been  accomplished  in  the  other.  One  must  also  take 
into  consideration  the  age,  habits,  and  social  condition  of 
the  eczematous  patient.  In  our  experience,  eczema  is  more 
curable  in  the  young  than  in  the  old,  in  people  of  temperate 
habits  than  in  those  who  indulge  in  excesses  of  any  sort, 
and,  as  in  all  other  diseases,  the  ability  of  the  patient  to 
obtain  proper  food,  good  hygienic  surroundings,  etc., 
must,  as  a  matter  of  course,  influence  the  progress  of  the 
disease. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Sodii  hyposulphitis 5|v 

Glycerin! 3iv 

Tr.  cardamomi  co q.  s.  ad     §vj — M. 

S. — Two  teaspoonfuls  in  water  three  times  a  day  after  meals  as  a 
laxative. 

Hartzell. 


1 24  INFLAMMA  TIONS 

If— Pulv.  rhei, 

Sodii  bicarbonatis aa     oij 

Aquae  menthae  pip 3iv — M. 

S. — Teaspoonful  in  water  after  meals.    In  infantile  eczema. 

Van  Harlingen. 

1^ — Sodii  bicarbonatis gr.v 

Spt.  chloroformis n\j 

Aquse  anethi  dil 3j — M. 

S. — Dose  for  a  child  of  one  year  of  age.    In  infantile  eczema. 

Crocker. 

1$ — Pptassii  citratis 5jj 

Liq.  potassii  arsenitis 5j-oij 

Tr.  nucis  vomicse oij 

Tr.  cichon.  comp 5iv — M. 

S. — Teaspoonful  in  water  after  meals.    As  a  tonic  and  altcrat  ivo. 

Bulkley. 

1^ — Glycerinse  plumbi  subacetatis,  B.  P.       .      .       Sss 

Liq.  carbonis  detergentis 3jss 

Aquae  rosae q.  s.  ad     5vj — M. 

S. — As  a  lotion  in  pustular  eczema  of  the  scalp  in  adults. 

Crocker. 

1$ — Ung.  zinci  oxidi 3j 

Sulphur,  prsecip gr.  xv 

Glycerini 5ss — M. 

S. — In  eczema  of  the  lips.  Payne. 

1^ — Anthrasol oj 

Olei  olivas 5|« 

Zinci  oxidi 3ij — M. 

llichter. 

1^ — Tumenoli-ammon 5ss-j 

^Ether.  sulph., 
Spt.  vini  rectificat., 

Aquae  destillatse aa  q.  s.  ad     5v — M. 

S. — In  scaly  eczema. 

1$ — Lenigallol, 

Anthrasol aa     oij 

Ung.  zinci  oxidi 5ijss — M. 

Kromayer 

I}— Pittylene gr.  x-1 

Zinci  oxidi, 

Amyli aa     gr.  c 

Aquae  destillatse q.  s.  ad    5j — M. 

Joseph. 


ECZEMA  125 

R — Lenigallol 5j-ij 

Zinci  oxidi, 

Amyli aa  5ss 

Petrolati 5j— M. 

1$ — Empyroformi, 

Zinci  oxidi aa  gr.  xxv-1 

Vaselini, 

Lanolini aa  5iv — M. 

Weisz. 

R — Zinci  oxidi 3vj 

Lanolini 5ij 

Olei  olivse 5j 

Liq.  calcis 5j — M. 

S. — A  soothing  cream  in  acute  eczema.  Morris. 


1$  —  Sulphuris  pnccip  

.      .     gr.  xl 

Naphthol      ........ 

.      .     gr.  xx 

Morphinae  acetat  
Zinci  carbonatis       

:  :  If 

Ung.  aq.  rosae    

.     .     5j—  M. 

S.  —  Apply  twice  daily.    In  eczema. 

Duhring. 

R  —  Mentholis 

er.  v 

Acidi  salicylici gr.  x 

Pulv.  amyli, 

Zinci  oxidi aa  3ij 

Vaselini 3ij — M. 

S. — Apply  twice  daily.    In  eczema  of  face.  Brown. 

!$ — Ichthyolis gr.  xxx 

Pulv.  amyli, 

Zinci  oxidi    .      . aa  oij 

Vaselini 5iv — M. 

S. — Apply  twice  daily.    In  eczema  harbor-.  Brown. 

1} — Tumenoli-ammon 3ij-5j 

Zinci  oxidi, 

Bismuth,  subnit aa     3ij 

Ung.  simplicis, 

Ung.  aq.  rosse aa     5ij— M. 

S. — In  acute  eczema. 

R — Hydrarg.  chlor.  mitis 3ss 

Ung.  picis  liquidse, 

Ung.  zinci  oxidi aa  3ss — M. 

S. — In  scaly  eczema  of  the  hands. 


126  INFLAMMATIONS 


ULCUS  VARICOSUS. 

Description. — This  form  of  ulcer  begins  in  middle  life  on 
the  anterior  aspect  of  the  leg  in  multipart  and  laboring  men 
afflicted  with  varicose  veins.  It  is  rarely  seen  among  the 
well-to-do,  but  appears  as  an  important  item  in  the  reports 
of  city  out-clinics  and  hospitals.  It  owns  a  threefold 
causation:  the  varicose  condition  with  much  standing  and 
continued  muscular  exertion  retarding  the  return  of  the 
blood  stream  from  the  lower  extremities  and  thus  lowering 
the  nutrition  of  the  tissues;  frequently  a  general  lowering 
of  resistance  from  insufficient  or  improper  food,  alcoholism, 
arteriosclerosis,  renal  or  cardiac  incompetence,  etc.,  and, 
lastly,  an  infected  traumatism  as  its  starting  point.  This 
may  be  a  nail-scratch  occasioned  by  the  pruritic  eczema 
which  so  often  precedes  and  accompanies  these  ulcers,  or 
one  of  the  slight  injuries  to  which  the  shin  region  is  so 
subject.  Usually  beginning  on  the  lower  half  of  the  anterior 
aspect,  it  extends  vertically  and  laterally,  in  bad  cases 
encroaching  far  around  on  each  side,  but  rarely  meeting 
behind.  Veins  may  be  opened  and  dangerous  hemorrhage 
sometimes  occurs.  These  lesions  are  often  extremely  pain- 
ful and,  as  a  rule,  refractory  to  treatment,  occurring  as  they 
do  hi  subjects  in  whom  the  hygienic  desiderata,  with  proper 
rest,  cleanliness,  and  feeding,  cannot  be  realized. 

Treatment. — The  advent  in  a  clinic  of  another  case  of  leg 
ulcer  rarely  excites  much  enthusiasm,  so  that  these  lesions 
generally  receive  perfunctory  and  routine  attention,  occa- 
sionally varied  with  spasmodic  trials  of  some  new  method. 
Treatment,  in  order  to  be  successful,  should  methodically 
take  up  the  various  indications  presented  in  each  particular 
case. 

These  indications  are : 

1.  To  rectify  as  far  as  possible  existing  morbid  general 
conditions. 

2.  To  assist  the  local  circulation. 

3.  To  subdue  inflammation. 


ULCUS  VARICOSUS  127 

4.  To  relieve  pain. 

5.  To  cleanse  the  surface  and  sterilize   it  as   much  as 
may  be. 

6.  To  stimulate  granulations. 

7.  To  promote  new  epithelial    formation    and  cicatri- 
zation. 

1.  General  Treatment. — This  includes  the  treatment  of 
diathetic  conditions  such  as  malaria,  gout,  alcoholism, 
anemia,  or  scurvy,  and  an  attempt  at  the  management, 
at  least,  of  tuberculosis,  heart  disease,  hepatic  or  renal 
cirrhosis,  arteriosclerosis,  diabetes,  etc.     Many  cases  re- 
quire more  and  better  food   and  rest,  all  of  which  can 
generally  be  secured  by  a  few  weeks'  stay  in  hospital.    Most 
cases  will  be  benefited   by  such   agents  as  iron,  arsenic, 
cod-liver  oil,  the  hypophosphites,  etc.,  and  a  few  by  alcohol 
in  medicinal  doses.     Arbour  Stevens  advises  15  gr.  doses 
of  calcium  chloride,  three  times  a  day,  in  foul-smelling 
cases,  and  later  2-gr.  doses  of  calcium  iodide,  under  which, 
he  says,  the  ulcers  heal  with  marvellous  rapidity. 

2.  Improvement   of    the   Local   Circulation. — The  best 
method  of  meeting  this  indication  is  one  unfortunately  not 
available  in  the  majority  of  cases,  namely,  prolonged  rest 
in  bed.    Its  benefits  are  greatly  enhanced  by  elevating  the 
extremity.     We  have  seen  deep  ulcers  which  had  nearly 
surrounded  the  leg,  successfully  treated  at  the  St.  Louis 
City  institutions  by  swinging  them  in  a  Hodgen  splint.    It 
is  doubtful,  however,  whether  the  healing  of  such  cases  is 
worth  the  while,  as  they  invariably  break  down  again  soon 
after  the  individual  returns  to  his  former  mode  of  life. 
Amputation  is  probably  the  best  solution  of  the  problem  in 
such  cases. 

Next  in  point  of  efficiency  is  a  well-applied  bandage 
extending  from  the  toes  to  the  knee.  This  may  be  of 
muslin,  but  better  of  flannel.  The  Martin  rubber  bandage  is 
objectionable  on  account  of  its  imperviousness.  It  is  rarely 
tolerated  in  hot  weather.  Far  better  is  the  elastic  web 
bandage  applied  over  a  long,  thin  stocking,  as  described 
in  the  article  on  eczema  of  the  legs.  Volkmann  improved 


128  INFLAMMATIONS 

upon  the  usual  methods  of  support  by  fitting  a  thick  layer 
of  cotton  into  and  over  the  ulcer.  This  is  firmly  bandaged 
on  and  left  in  place  until  the  odor  becomes  foul.  Lister 
modified  this  by  covering  the  ulcer  with  a  dry  antiseptic 
dressing  after  sterilizing  the  surface.  Strapping  is  a  well- 
known  and  reliable  procedure.  Strips  of  adhesive  plaster 
from  one-half  to  one  inch  wide  and  long  enough  to  extend 
three-quarters  of  the  way  around  the  leg  are  applied 
smoothly  and  evenly,  so  as  to  overlap  about  one-third  their 
width.  They  should  begin  one  inch  or  more  below  the 
ulcer  and  extend  as  much  above  it.  Strips  of  metal  have 
been  applied  over  thickened  edges  so  as  to  exert  pressure. 
Unna's  glycerin-gelatin  is  designed  to  afford  support  by 
compression  and  protection.  It  consists  of  glycerin  and 
water,  10  parts  each;  zinc  oxide  and  gelatin,  4  parts  each. 
The  leg  being  cleaned,  the  mixture  is  warmed  in  a  water 
bath  until  fluid,  and  then  painted  on.  Over  this  is  applied 
a  gauze  bandage,  and  then  another  layer  of  the  paint. 
This  may  remain  in  place  for  weeks,  a  window  being  cut 
over  the  ulcer  if  discharge  is  abundant. 

The  varicose  veins  above  the  ulcer  may  require  ligation 
or  excision.  These  measures  sometimes  relieve  the  super- 
ficial stasis  by  diverting  the  blood  current  into  deeper 
vessels. 

In  some  cases  the  blood  supply,  so  far  from  being  exces- 
sive, is  deficient,  owing  to  the  fact  that  the  base  and  borders 
of  the  ulcer  are  firmly  bound  down  by  dense  cicatriciul 
tissue.  Various  operations  have  been  devised  to  meet  this 
condition.  Liston  "starred"  the  ulcer  by  a  number  of 
radiating  incisions  through  the  base  and  edges.  Harbordt 
practised  deep  cross-hatching;  Nussbaum  made  a  circular 
incision  through  the  normal  skin  around  the  ulcer;  Hod  gen, 
instead  of  a  single  incision,  made  a  series  of  short,  overlap- 
ping cuts  surrounding  the  lesion. 

3.  Subduing  Inflammation. — When  the  surrounding  tis- 
sues are  acutely  inflamed,  as  is  so  often  the  case  when  the 
patient  is  first  seen,  we  must  resort  to  cooling  and  sedative, 
moist  applications,  with  elevation  of  the  member  and  rest. 


ULCUS  VARICOSVS  129 

Thiersch's  solution  (boric  acid,  5  parts;  salicylic  acid,  1 
part ;  water,  500  parts)  is  probably  equal  to  any. 

4.  To  Relieve  Pain. — Orthoform    is  useful    in  20  per 
cent,  ointment.      Cocaine  or  morphine  in  2  per  cent,  oint- 
ment will  often  be  demanded.    Rest  and  elevation  of  the 
part  are  the  best  methods  at  our  command. 

5.  Cleaning   and  f  Sterilizing   the   Surface. — A  number 
of  substances  and  methods  have  been  employed  for  this 
purpose.     Among  solutions  those   of  mercuric   chloride 
1  to  1000  and  carbolic  acid  2  per  cent,  are  well  and  favor- 
ably known.    Hydrogen  peroxide  solution,  formalin  1  per 
cent.,  and  chloral  hydrate  1  per  cent,  are  efficient.    Zeimer 
employs  chlorinated  lime  1  per  cent.,  which  he  says  not  only 
dries  up  secretion,  but  gives  the  granulations  a  healthy 
appearance  and  usually  brings  about  perfect  skin  forma- 
tion.    Waughop's  plan  of  packing  the  ulcer  with  gauze 
soaked  in  a  saturated  solution  of  potassium  permanganate 
is  probably  efficient,  but  unnecessarily  cruel. 

Among  powders  the  iodine  preparations  are  much  used, 
iodoform  still  retaining  the  preference  in  spite  of  the  many 
less  odorous  contestants  for  its  position.  We  should 
remember  that  in  a  relatively  large  proportion  of  individuals 
it  will  excite  severe  dermatitis  and  sometimes  grave  general 
toxic  symptoms.  It  is  none  the  less  too  valuable  to  be 
wholly  laid  aside.  Blum  and  Baerwald  found  a  service- 
able preparation  in  bismuth  loretinate,  an  astringent  and 
antiseptic  iodine  compound.  Naphthalin  is  highly  recom- 
mended. Ferments  such  as  yeast,  papoid,  caroid,  and 
protonuclein  often  do  well. 

Among  other  agents,  the  silver  stick  is  an  old  acquaint- 
ance. Von  Langsdorf  scrubs  the  ulcer  and  leg  with  soft 
soap  and  covers  the  former  with  a  paste  of  calomel.  Over 
this  he  puts  common  salt  and  dresses  with  gauze  and 
absorbent  cotton,  after  which  the  application  is  removed 
and  the  surface  washed.  The  method  is  very  painful. 
Simonelli  applies  50  parts  of  common  salt  and  5  of  menthol. 
Sabouraud,  in  stubborn  cases,  rubs  the  surface  with  the 
silver  stick  and  then  with  a  zinc  rod,  freshly  scraped  so  as 
9 


130  INFLAMMATIONS 

to  expose  a  shining  surface;  acid  zinc  nitrate  is  formed, 
causing  much  pain.  The  ulcer  is  afterward  dressed  with 
ferrous  sulphate  as  described  a  little  below.  Cataphoresis 
combined  with  electrolysis  is  used  by  Edwards,  a  zinc  or 
zinc  mercury  positive  electrode  being  applied  to  the  surface. 
Stoker  employed  oxygen,  and  later  ozone;  an  india-rubber 
bag  with  two  large  openings  embraces  the  limb  above  and 
below  the  lesion.  The  gas  is  admitted  into  the  chamber 
so  formed,  which  is  refilled  every  five  or  six  hours.  River 
uses  chlorine  gas.  KC1O3  and  HC1  are  put  in  a  stoppered 
jar.  A  disk  of  white  paper  separates  the  chemicals  from 
some  absorbent  wool,  which  when  saturated  with  the  gas, 
is  placed  over  the  ulcer,  quickly  covered  with  gutta-percha 
tissue,  and  bound  on.  Tarabrin  brings  the  paquelin 
cautery  to  a  dull  red  and  moves  it  about  at  a  distance  of 
5  or  6  cm.  from  the  surface. 

6.  Stimulating  Granulations. — Several  of  the  methods 
enumerated  in  the  last  division  of  the  subject  are  useful 
here  also,  notably  the  use  of  the  iodine  compounds;  among 
others  aristol,  nosophen,  iodol,  and  xe reform  may  be 
mentioned.  The  bismuth  salts  are  useful,  especially  the 
subgallate,  known  as  dermatol,  as  well  as  salol  and 
antipyrine,  salicylic  acid,  sulphur,  camphor,  ichthyol, 
balsam  of  Peru,  myrrh,  and  benzoin.  Any  of  the  above 
may  be  used  pure  or  in  ointments.  Among  solutions  we 
have  those  of  potassium  permanganate,  zinc  or  copper 
sulphate,  and  silver  nitrate.  We  have  witnessed  marvellous 
improvement  from  a  single  application  of  the  preparation 
of  ox-blood  known  as  bovinine.  Sabouraud  finds  ferrous 
carbonate  an  excellent  agent,  especially  useful  in  old,  deep 
ulcers.  The  entire  cavity  should  be  filled  with  the  powder, 
over  which  wadding  and  a  bandage  are  applied.  As  an 
ointment  it  may  be  used  in  vaselin  1  to  40.  Hamilton's 
method  of  sponge  grafting  hastens  the  filling  of  the  ulcer. 

The  ovrays  have  found  favor  with  some  practitioners. 
Mackie  uses  the  high-frequency  spark.  Marquant  obtained 
striking  results  with  the  brush  discharge  from  the  positive 
pole  of  a  static  machine  used  twice  a  week. 


ECZEMA  SEBORRHOICUM  131 

7.  To  Promote  Cicatrization. — Many  of  the  agents  above 
mentioned  are  also  useful  here.  The  occasional  light 
touching  of  the  granulations  just  within  the  healthy 
border  with  the  silver  stick  is  a  favorite  procedure.  Redun- 
dant granulations  may  be  pared  off,  treated  by  pressure, 
or  bored  through  with  caustic.  Ointments  of  a  bland  or 
mildly  stimulating  nature  are  useful  at  this  stage.  Skin 
grafting  finds  an  especial  application  here  in  hastening 
the  closing  over  of  large  areas  and  securing  a  good  skin 
surface.  (For  a  full  exposition  of  methods  see  article  on 
Skin  Grafting  in  Part  II.) 


ECZEMA  SEBORRHOICUM. 

Description. — According  to  Unna,  the  point  of  departure 
for  nearly  all  cases  of  seborrheal  eczema  is  the  scalp,  less 
often  the  margin  of  the  eyelids,  the  axillae,  or  the  cruro- 
scrotal  fold. 

It  may  remain  localized  on  the  scalp  for  years,  or  spread 
to  contiguous  parts,  such  as  the  ears,  forehead,  temple,  and 
neck.  The  sternal,  interscapular,  and  umbilical  regions 
are  also  favorite  sites.  Sometimes  the  disease  may  be 
observed  on  parts  of  the  body  distant  from  the  scalp,  as  the 
legs,  for  example,  the  intervening  skin  being  unaffected; 
or,  again,  the  whole  body  may  be  invaded  (pityriasis  rubra 
seborrhoica). 

On  the  scalp  the  vertex  is  the  usual  seat  of  the  disorder, 
although  the  whole  hairy  region  may  be  involved.  There 
is  often  present  more  or  less  profuse  branny  scaling  of  a 
slate-gray  color,  the  skin  being  pale  and  dry  (pityriasis 
capitis).  In  the  course  of  time  the  hairs  become  dry  and 
lusterless,  and  after  months  or  years  a  certain  amount  of 
baldness  results  (alopecia  pityrodes). 

The  scaling,  however,  may  be  much  increased,  so  as  to 
cause  thick,  adherent  masses  that  surround  the  hairs  and 
ensheath  them;  or  the  scales  may  be  softer  and  friable;  or 
the  scalp  is  covered  with  soft,  yellow  crusts,  and  the  hair 


1 32  IN  FLAM  MA  TIONS 

becomes  oily  and  shiny.  Beyond  slight  itching,  the  sub- 
jective symptoms  are  not  marked.  Here  and  there  over  the 
scalp  a  generalized  or  patchy  redness  may  develop,  or 
reddish-yellow,  sharply  limited,  round  or  oval,  crusted  or 
moist  lesions  may  appear,  sometimes  extending  to  the 
temporal  and  parietal  regions  and  even  to  the  ears  and 
parts  of  the  face.  Along  the  border  of  the  hair  of  the  fore- 
head and  neck,  it  is  not  unusual  to  see  a  red  band  covered 
with  scales  or  crusts  (corona  seborrhoica).  The  eyebrows, 
beard,  and  mustache  may  be  involved  in  varying  degrees. 
Along  the  margin  of  the  lids  the  disease  is  frequent  and  its 
association  with  "chronic  dandruff"  we  have  often  pointed 
out  to  ophthalmologists.  We  have  every  reason  to  believe, 
moreover,  that  many  styes  have  the  same  etiology,  and  that 
the  best  way  to  stop  the  styes  is  to  treat  the  scalp. 

The  region  of  the  trunk  is  frequently  affected,  particu- 
larly the  sternum  and  the  interscapular  space.  Here  the 
lesions  are  to  be  found  in  circles  or  segments  of  circles, 
which  by  peripheral  enlargement  and  subsequent  coales- 
cence in  time  present  circinate  figures.  The  disease  in 
these  situations  corresponds  to  the  seborrhea  corporis  of 
Duhring  and  so-called  lichen  circumscriptus.  In  the 
axillae  and  groins  sharply  defined,  reddish  patches,  with  a 
tendency  to  advance  in  circinate  outlines,  and  not  uncom- 
monly exuding,  are  of  frequent  occurrence. 

Certain  types  of  seborrheal  eczema  are  also  encountered 
that  bear  a  close  resemblance  to  psoriasis,  but  differ  from 
it  in  leaving  the  elbows  and  knees  free,  and  in  the  fact  that 
the  lesions  are  covered  with  fatty  scales.  This  is  the  sebor- 
rhea psoriasiforme  of  authors. 

Etiology. — Among  the  presumed  external  causes  of  sebor- 
rheal eczema  should  be  mentioned  irritation  of  all  sorts, 
and  probably  direct  contagion.  We  quite  agree  with  Stel- 
wagon  in  believing  that  among  general  causes  digestive 
disturbances  often  act  as  predisposing  influences,  at  least. 
There  is  no  doubt  that  seborrheal  eczema  is  of  parasitic 
origin. 

Prognosis. — The  prognosis  is  usually  good,  but  relapses 
may  be  expected. 


ECZEMA  SEBORRHOICUM  133 

Treatment. — The  internal  treatment,  when  demanded, 
is  that  of  eczema,  with  special  attention  to  the  digestive 
organs.  We  believe  that  most  excellent  results  are  obtained 
with  cod-liver  oil  (see  eczema)  in  the  persistent  seborrheal 
eczemas  of  children,  especially  in  cases  where  there  exists 
involvement  of  the  scalp,  eyebrows,  and  eyelashes.  In 
many  of  these  cases  the  local  affection  apparently  follows 
in  the  wake  of  the  eruptive  fevers,  and  local  treatment 
alone  is  of  only  temporary  benefit. 

Locally,  the  care  of  the  scalp  is  very  important,  since  it 
is  a  matter  of  clinical  experience  that  the  disease  may 
spread  thence  to  other  parts  of  the  body. 

As  a  shampoo  in  the  pityriasic  form  of  the  disease,  there 
is  nothing  better  than  equal  parts  of  green  soap  and  cologne, 
mentioned  in  connection  with  alopecia  pityrodes  (q.v.), 
where  also  the  treatment  of  seborrhea  of  the  scalp  will  be 
more  fully  considered. 

Sulphur,  resorcin,  and  salicylic  acid  are  the  most  useful 
drugs  in  the  local  management.  Elliott  states  that  lotions 
are  more  beneficial  on  hairy  parts  than  salves,  and  recom- 
mends one  containing  resorcin,  3  to  10  per  cent.,  in  equal 
parts  of  alcohol  and  water.  Brayton  suggests  a  lotion 
of  salicylic  acid  and  resorcin  in  the  same  proportions  of 
alcohol  and  water.  Norman  Walker  gives  the  following 
prescription : 

1$ — Acidi  salicylic! 5j-iv 

Olei  ricini 5ij-vj 

Olei  rosse  geran rr^x 

Alcoholis q.  s.  ad  Bvj — M. 

The  various  lotions  are  best  applied  to  the  scalp  by  means 
of  a  medicine  dropper,  thus  allowing  the  medicament  to  be 
placed  directly  on  the  scalp. 

It  has  always  seemed  to  us  that  in  the  dry,  scaly  forms 
of  seborrhea,  wherever  situated,  an  ointment  gives  better 
results : 

1$ — Resorcini gr.  x 

Sulphuris  prsecipitati 5j 

Vaselini 3j — M. 


1 34  INF  LAM  MA  TIONS 

T$ — Acidi  salicylici         3j 

Sulphuris  prsecipitati 3j-ij 

Vaselini 3j 

Olei  limonis q.  s. — M. 

The  acute  forms  require  the  usual  treatment  prescribed 
in  similar  cases  of  eczema.  On  the  hairy  scalp  a  soothing 
lotion  of  equal  parts  of  oil  of  sweet  almonds  and  lime-water, 
with  £  to  1  per  cent,  of  carbolic  acid,  should  be  applied 
until  the  acute  symptoms  abate.  Intertriginous  forms  may 
be  satisfactorily  treated  by  Lassar's  or  Ihle's  pastes.  (See 
Eczema.)  When  chronic,  infiltrated  eruptions  are  encoun- 
tered, stronger  remedies  will  be  demanded,  such  as  chrys- 
arobin,  pyrogallol,  the  tars,  etc.,  as  in  psoriasis.  In  the 
psoriasiform  type,  with  dry,  scaling  patches,  so  often  found 
at  the  borders  of  the  scalp,  white  precipitate  and  tar  some- 
times succeed  where  other  remedies  fail. 

]$ — Hydrargyri  ammoniati 9j 

Liq.  carbonis  detergentis 5j 

Vaselini 5j — M. 

Lesions  have  been  removed  by  moderate  doses  of  the 
x-rays.  The  fact,  however,  has  little  practical  interest,  as 
the  method  is  not  to  be  advised  in  a  disease  for  which  we 
possess  surer,  safer,  and  simpler  agents  of  cure.  Stelwagon, 
however,  suggests  the  method  in  obstinate  facial  cases. 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Acidi  salicylici gr.  x 

Sulphuris  prsccipitati gr.  x 

Zinci  oxidi 3ij 

Vaselini q.  s.  ad     5j — M. 

Walker. 

1^ — Sulphuris  pnecipitati gr.  xxx-xl 

Acidi  salicylici gr.  x 

Pulv.  amyli, 

Zinci  oxidi     .  aa     5jss 

Petrolati 5iv — M. 

S. — For  use  on  non-hairy  parts.  Stelwagon. 

1^ — Sulphuris  prsecipitati 5ij 

Balsami  Peruviani TT^X 

Vaselini 5j— M. 


DERMATITIS  REPENS  135 

$ — Sulphuris  praecipitati gr.  xx 

Olei  cadini Sijss 

Lanolini 3v 

Vaselini  .  gj — M 

Sabouraud. 


DERMATITIS  REPENS. 

Description. — Under  this  name  Crocker  was  the  first  to 
describe  a  form  of  wandering  dermatitis,  following  upon 
some  local  injury.  It  usually  begins  on  one  of  the  upper 
extremities,  probably  on  account  of  the  greater  frequency 
of  exposure  of  these  parts.  The  initial  point  of  departure 
may  have  been  produced  by  the  most  diverse  agencies, 
e.  g.,  a  burn,  a  splinter,  etc.  The  advancing  border  is 
sharply  limited  and  irregular  in  outline,  while  the 
peripheral  extension  of  the  disease  is  marked  by  continu- 
ous undermining  of  the  epidermis  with  a  serous  or  puru- 
lent exudation,  or  in  the  form  of  vesicles  or  small  blebs. 
The  lesions  may  exceptionally  be  papular.  While  creeping 
forward  at  one  point,  it  may  heal  at  another,  but  the  ten- 
dency is  toward  a  continuous  advance,  often  involving  a 
considerable  surface. 

Where  the  process  has  passed  over  a  given  region  the 
skin  has  a  glistening,  red  and  somewhat  thin  appearance. 
Crocker  regards  the  disorder  as  a  peripheral  neuritis 
starting  in  some,  perhaps  trifling,  injury,  and  kept  up  by  a 
secondary  parasitic  infection. 

Under  the  name  of  acrodermatitis  perstans  Hallopeau 
and  others  describe  a  very  similar  condition,  which  also 
has  its  beginning  on  the  extremities — usually  one  finger — 
and  by  gradual  development  of  fresh  lesions  involves 
other  fingers,  the  nails,  and  parts  of  the  hands.  The  first 
lesions  are  vesicles  and  pustules.  Associated  with  the 
local  expressions  of  the  disease  other  parts  of  the  body  may 
exhibit  secondary  eruptions  of  an  erythematosquamous 
type. 

Treatment. — No  internal  treatment  has  been  found 
beneficial,  but  locally  antiseptics,  e  g.,  permanganate  of 


136  INFLAMMATIONS 

potassium  in  10  per  cent,  solution,  have  been  found  service- 
able, also  salicylic  acid,  iodoform,  and  aristol.  We  have 
seen  a  10  per  cent,  ointment  of  xeroform  stop  the  progress 
of  the  disease.  Hyde  and  Montgomery  have  obtained 
good  results  from  a  saturated  solution  of  sodium  hypo- 
sulphite, and  from  a  strong  white  precipitate  salve. 


PRURIGO. 

Description. — Prurigo  is  a  chronic  inflammatory  disease 
of  the  skin  that  develops  first  in  childhood,  and  is  charac- 
terized by  an  eruption  of  pale,  discrete  papules,  attended 
by  severe  itching.  The  disease,  a  very  rare  one  in  America, 
begins  in  infancy  and  makes  its  first  appearance  in  the 
form  of  urticarial  wheals,  which  are  after  a  season  fol- 
lowed by  the  papular  eruption. 

The  papules  are  mostly  of  the  size  of  hemp  seeds,  and  at 
first  are  of  the  color  of  the  skin,  and  more  easily  felt  than 
seen,  but  in  the  course  of  time,  as  a  result  of  the  violent 
itching,  which  is  the  chief  symptom,  they  become  darker, 
more  appreciable  to  the  eye,  and  capped  with  blood  or 
serum  crusts.  The  extensor  surfaces  of  the  limbs  are  most 
involved,  while  the  flexor  aspects,  the  face  and  scalp,  palms, 
soles,  penis  and  scrotum  are  rarely,  if  at  all,  attacked. 

According  to  the  intensity  of  the  accompanying  pruritus, 
which  will  depend  upon  the  extent  and  distribution  of  the 
prurigo  nodules,  the  secondary  changes  of  the  skin  will  be 
more  or  less  pronounced,  viz.,  infiltration,  pigmentation, 
desquamation,  the  deepening  of  the  normal  integumentary 
furrows,  etc.  In  the  so-called  prurigo  ferox  there  is  an 
exaggeration  of  all  these  symptoms. 

Treatment. — Since  so  little  is  known  of  the  essential 
etiology  of  prurigo,  internal  treatment  is  mainly  directed 
to  improving  the  nutrition  of  the  patient  and  securing 
proper  hygienic  conditions  of  life.  Cod-liver  oil  is  often  of 
benefit.  Certain  internal  remedies  have  been  given  for 
the  relief  of  the  tormenting  pruritus,  such  as  carbolic  acid, 


PSORiAsrs  137 

the  bromides,  pilocarpine  hypodermically,  and  the  tincture 
of  cannabis  indica. 

A  great  variety  of  local  measures  have  been  advocated, 
such  as  warm  and  cool  baths,  sulphur,  mercurial,  alkaline 
and  tar  baths,  and  the  application  of  lotions  and  ointments 
of  sulphur,  tar,  and  naphthol.  The  preparations  of  tar 
and  sulphur  may  be  used  in  conjunction  with  baths,  and 
sometimes  in  bad  cases  better  results  are  obtained  by 
rubbing  the  parts  with  green  soap,  followed  by  the  bath 
and  the  subsequent  application  of  the  selected  salve. 

Pick  claims  satisfactory  results  with  the  glycerin  gela- 
tin. In  the  mild  cases  seen  in  this  country,  lotions  of 
menthol  and  carbolic  acid  give  at  least  temporary  relief 
from  the  itching. 

The  X-rays. — Belot  obtained  an  apparent  cure  in  a  case 
of  Hebra's  prurigo  by  a  single  irradiation  to  each  region. 
The  itching  was  relieved  within  forty-eight  hours. 


PSORIASIS. 

Description. — Psoriasis  is  a  chronic,  inflammatory  dis- 
ease of  the  skin,  characterized  by  variously  sized  lesions 
having  red  bases,  covered  with  white,  mother-of-pearl 
scales,  and  affecting  by  preference  the  extensor  surfaces  of 
the  body. 

The  disorder  in  its  earliest  expression  consists  of  minute 
reddish  spots  or  points  of  congestion  which,  practically 
from  the  beginning,  may  be  said  to  show  evidence  of  the 
characteristic  free  scaling.  The  eruption  is  usually  made 
up  of  multiple  lesions,  and  these  by  peripheral  extension 
grow  to  the  diameter  of  large  or  small  coins.  Having 
attained  a  certain  definite  size,  the  papules  may  remain 
discrete;  in  other  instances  the  lesions  coalesce  and  form 
in  this  way  patches  of  variable  sizes  and  shapes,  generally 
with  a  tendency  to  a  circular  arrangement. 

But  whatever  forms  or  dimensions  the  lesions  of  psoriasis 
may  assume,  if  studied  in  detail  it  will  be  seen  that  they 


138  INFLAMMATIONS 

have  certain  definite  and  determinate  features  that  are 
rarely  absent.  They  are  infiltrated,  elevated,  sharply 
defined,  have  red  bases,  and  are  covered  with  white,  imbri- 
cated, often  easily  detachable  scales,  which  upon  removal 
will  exhibit  a  punctate,  bleeding  surface.  According  to 
Bulkley,  after  the  scales  have  been  thoroughly  removed,  a 
thin  pellicle  may  be  peeled  off  the  surface  of  the  patch. 
The  scaling  in  psoriasis  presents  considerable  variations. 
It  is  most  abundant  in  the  active  stage  of  the  disease,  being 
scantier  in  the  beginning  and  in  the  period  of  decline,  and 
it  is  said  that  the  scales  are  thinner  in  females  than  in 
males ;  and,  moreover,  under  all  circumstances,  the  thicker 
the  epidermis  the  more  plentiful  the  scales. 

The  patches  of  psoriasis,  unlike  those  of  eczema,  are 
sharply  defined  against  the  unaffected  skin,  and  the  larger 
lesions  are  surrounded  by  a  delicate  red  areola,  the  scale 
formation  not  keeping  pace  with  the  extension  of  the 
psoriatic  process.  In  the  further  evolutions  of  the  plaques 
the  skin  becomes  considerably  infiltrated,  which  condition 
in  some  situations  gives  rise  to  painful  cracks  and  fissures. 

The  involution  of  the  patches  begins  in  the  centre,  and 
often  in  this  way  various  bizarre  figures  are  produced,  the 
disease  spreading  at  the  periphery,  and  merging  into 
adjacent  lesions. 

The  lesions  upon  their  disappearance  leave  no  permanent 
traces  behind,  but  upon  the  legs  a  considerable  discolora- 
tion may  persist  for  a  season. 

The  eruption  is  at  all  times  absolutely  dry — there  is  no 
discharge  feature.  Itching  is  often  entirely  absent,  but  we 
have  occasionally  seen  it  very  severe.  In  fact,  aside  from 
the  bodily  disfigurement,  the  patient  is  rarely  made  con- 
scious of  his  affliction.1 

Psoriasis  affects  by  preference  the  extensor  surfaces  of 
the  body,  and  more  particularly  the  elbows  and  knees.  In 

1  Some  French  authorities  (Besnier,  Bourdillon)  declare  that  if  a 
great  number  of  cases  of  psoriasis  are  carefully  studied,  it  will  be 
found  that  affections  of  the  joints  are  present  in  a  certain  proportion 
of  them — according  to  Besnier  five  times  in  a  hundred. 


PSORIASIS  139 

our  experience  the  scalp  is  usually  involved,  and  most 
patients  with  psoriasis  will  tell  you  that  they  have  had 
"dandruff"  for  a  long  time. 

The  disease  may  attack  any  part  of  the  body,  and  is 
almost  invariably  symmetrical.  In  outbreaks  of  any  extent 
the  trunk  always  suffers,  but  less  rarely  the  face,  and  more 
rarely  still  the  palms,  soles,  penis,  and  scrotum. 

The  finger  and  toe  nails  usually  suffer  by  extension  of 
the  disease  from  the  hands  and  fingers,  or  the  feet.  The 
nails  may  be  alone  attacked.  They  become  rough,  thick, 
quite  brittle,  and  streaked  by  longitudinal  and  transverse 
ridges,  and,  as  in  lichen  ruber,  may  become  lifted  up  and 
project  away  from  the  nail  bed. 

Psoriasis  on  the  scalp  rarely  leads  to  even  temporary  loss 
of  hair.  In  this  region  it  may  occur  in  bands  and  streaks 
or  as  discrete  patches.  According  to  Greenough  psoriasis 
of  the  hairy  scalp  shows  more  or  less  epithelial  scales,  but 
not  the  redness  common  in  other  situations.  The  exten- 
sion of  the  process  from  the  scalp  to  the  forehead,  in  the 
shape  of  a  band  running  along  the  border  of  the  hair,  is 
very  characteristic. 

Psoriasis,  while  very  constant  in  its  eruptive  features, 
exhibits  great  variety  as  to  the  course  and  extent  of  the 
disease  as  a  whole.  It  is  essentially  a  chronic  malady, 
although  a  given  outbreak  may  have  an  acute  aspect. 
Frequent  relapse  is  the  rule;  sometimes  one  or  more 
attacks  occur  in  the  course  of  a  year,  or,  again,  a  consider- 
ably longer  period  may  elapse.  In  some  cases  the  patient 
is  never  entirely  free  from  the  eruption.  The  amount  of 
surface  involved  also  varies  much.  The  eruption  may  be 
absolutely  universal,  or  limited  to  a  few  insignificant 
papules,  and  between  these  two  extremes  there  may  be  all 
grades  of  implication  of  the  skin.  We  have  generally 
observed  the  disease  to  be  worse  in  winter  and  better  in 
summer.  The  eruption  has  been  noted  to  disappear  during 
general  disturbances  of  nutrition,  e.  g.,  in  the  course  of 
typhoid  fever,  etc.  J.  C.  White  has  reported  a  case  in 
which  warty  growths  supervened  on  a  psoriasis,  followed 
in  turn  by  epitheliomatous  degeneration. 


140  INFLAMMATIONS 

Etiology. — The  etiology  of  psoriasis  is  not  known, 
although  various  theories,  neurotic,  toxemic,  or  parasitic, 
are  held  in  regard  to  its  nature.  Heredity  is  a  factor  of 
considerable  importance. 

Diagnosis. — The  diagnosis  of  psoriasis  offers,  as  a  rule, 
but  few  difficulties.  The  symptoms  are  very  characteristic 
and  pronounced;  an  eruption  consisting  of  imbricated 
white  scales,  seated  on  red  bases,  sharply  defined  from 
the  surrounding  integument,  affecting  the  extensor  surfaces, 
especially  the  elbows  and  knees,  and  almost  invariably 
involving  the  hairy  scalp,  itching  but  little  if  at  all,  and 
entirely  dry  throughout — are  all  features  whose  significance 
it  is  not  easy  to  mistake.  It  must  be  confessed,  however,  that 
atypical,  ill-defined  phases  of  the  disorder  are  sometimes 
present  that  render  considerable  care  in  diagnosis  neces- 
sary. The  following  diseases  should,  therefore,  be  differ- 
entiated, namely,  syphilis,  especially  the  scaling  types; 
squamous  eczema,  seborrhea,  and  lichen  planus. 

Prognosis. — Psoriasis  as  usually  encountered  does  not 
interfere  with  the  general  health,  and  is  only  of  importance 
from  the  disfigurement  and  discomfort  it  occasions. 
Relapses  are  the  rule,  but  their  frequency  and  the  extent  of 
the  eruption  will  vary  in  different  cases.  It  may  be  said  in 
a  general  way  that  a  given  outbreak  may  be  removed,  but 
the  time  necessary  to  accomplish  this  result  cannot  always 
be  precisely  stated ;  nor  can  the  physician  declare  how  long 
a  period  will  elapse  before  the  eruption  returns.  We 
believe  that  much  can  be  accomplished  in  modifying  the 
course  of  the  disease  by  constant  and  intelligent  supervision 
on  the  part  of  the  medical  attendant,  provided  he  has  the 
cooperation  of  the  patient  in  his  endeavors. 

Treatment. — It  is  often  of  considerable  importance  to 
treat  the  patient  as  well  as  the  psoriasis.  We  mean  by  this 
that  the  mere  empirical  administration  of  a  drug  must  be 
supplemented  or  superseded  by  attention  to  diet,  to  appar- 
ent defects  of  health,  and  a  study  of  personal  idiosyncrasies 
and  peculiarities.  For  example,  dyspepsia  must  be  cor- 
rected, anemia  relieved,  and  the  gouty  or  lithemic  state 
suitably  combated. 


PSORIASIS  141 

In  the  full-blooded  subject  of  gouty  tendencies  alkalies 
are  undoubtedly  efficient,  aided  perhaps  by  colchicum.  A. 
R.  Robinson  recommends  for  such  purpose  the  following 
mixture: 

I        1$ — Potassii  acetatis 5j 

Spiritus  setheris  nitrosi oiv 

Vini  colchici oij 

Syr.  aurantii 5jss 

Aquae  carui q.  s.  ad     5vj — M.       | 

S. — Dessertspoonful  in  a  wineglassful  of  water  after  meals.    jUM 

Arsenic  may  be  combined  with  this  mixture  in  suitable 
doses. 

When  the  eruption  is  of  an  acute  type  the  wine  of  anti- 
mony in  5-  or  6-minim  doses,  three  times  a  day,  may  be 
given  with  benefit,  as  recommended  by  Morris. 

Iron  is  of  great  value  in  children  who  appear  anemic 
and  out  of  health;  and  the  emulsion  of  cod-liver  oil  with 
the  hypophosphites  and  lactophosphate  of  lime  is  often 
administered  with  advantage. 

In  a  certain  number  of  cases,  probably  the  majority,  no 
especial  exciting  or  complicating  cause  can  be  detected, 
and  if  we  wish  to  treat  the  patient  internally  we  must 
have  recourse  to  empirical  remedies.  At  the  head  of  the 
list  stands  arsenic,  a  remedy  that  finds  its  especial  field  of 
utility  in  psoriasis,  the  disease  for  which  it  was  first  pre- 
scribed by  Girdlestone.  The  remedy  may  be  given  in  the 
form  of  Fowler's  solution,  Pearson's  solution,  the  Asiatic 
pills,  tablet  triturates,  powders,  or  in  fact  in  any  manner 
best  borne  by  the  patient.  In  this  country  and  in  England 
Fowler's  solution  given  immediately  after  meals  is  the 
favorite  mode  of  administration.  The  following  formula 
is  in  common  use: 

1$ — Liq.  potassii  arsenitis oij 

Vini  ferri q.  s.  ad     5iv — M. 

S. — Teaspoonful  in  wineglass  of  water  directly  after  meals. 

We  rarely  find  it  necessary,  or  think  it  advisable,  to  give 
more  than  5  minims  of  the  solution  to  an  adult,  as  we  believe 
that  any  good  to  be  got  from  it  may  be  obtained  from 


142  INFLAMMATIONS 

moderate  doses  long  continued.  In  the  beginning  it  is  well 
to  begin  with  even  smaller  doses  (1  to  2  minims),  and  pro- 
portional quantities  to  children,  although  they  bear  rela- 
tively larger  amounts  of  the  drug. 

Arsenic  acts  slowly,  and  if  there  are  no  centra-indications 
to  its  use  it  must  be  continued  for  weeks  before  its  thera- 
peutic value  can  be  determined.  While  it  cannot  be  denied 
that  arsenic  is  of  great  benefit  in  some  cases,  it  must  be 
admitted  that  its  action  is  capricious,  and  in  other  cases, 
where  it  is  perfectly  tolerated,  it  fails  of  any  good  effect. 
It  should  not  be  employed  in  acute  outbreaks,  and  it  is 
not  especially  effectual  in  old,  chronic,  diffuse  cases.  It  is 
most  beneficial  in  the  guttate  forms. 

A  convenient  formula  for  the  well-known  Asiatic  pills 
is  as  follows : 

1$, — Pulv.  acidi  arseniosi gr.  j-ij 

Pulv.  piperis  nigrse, 

Pulv.  glycyrrhizae  rad aa     9ij — M. 

Div.  in  pil.  No.  xl. 

S. — One  pill  after  meals. 

Hebra  was  in  the  habit  of  increasing  the  dose  to  the 
limit  of  tolerance.  The  method  is  not  to  be  recommended. 
The  same  may  be  said  of  the  hypodermic  injection  of 
Fowler's  solution,  a  mode  of  employment  that  would  not 
be  long  tolerated  in  private  practice.  Corlett  thinks  well 
of  the  bromide  of  arsenic  by  the  mouth. 

Among  other  remedies  for  internal  use  in  psoriasis,  that 
have  been  advocated  from  time  to  time,  may  be  mentioned 
cantharides,  tar,  carbolic  acid,  copaiba,  turpentine,  and 
phosphorus.  Some  years  ago  one  of  us1  made  a  trial  of 
chrysarobin  internally,  being  induced  thereto  by  Napier's 
experiments  with  the  drug,  but  we  soon  gave  up  the  practice 
as  being  of  doubtful  efficacy  and  certainly  very  disagree- 
able in  its  effects  on  the  patient.  The  huge  doses  of  iodide 
of  potassium  recently  recommended  by  Haslund  and  others 
we  have  not  tried,  and  think  them  dangerous. 

1  Hardaway. 


PSORIASIS  143 

A  few  years  since  Bramwell  first  advocated  the  treatment 
of  psoriasis  by  thyroid  extract,  and,  while  it  did  good  in 
some  cases,  the  result  on  the  whole  has  been  disappointing. 
Crocker  still  seems  to  think  highly  of  it  in  the  "right 
cases,"  but  he  does  not  clearly  define  the  indications  for 
its  use.1  Our  own  experience  is  far  from  gratifying,  and  we 
now  limit  its  employment  to  inveterate  forms  of  the  disease. 
Crocker  advises  that  only  one  tabloid  a  day  of  the  dried 
extract  should  be  given  at  first;  after  three  or  four  days 
two  may  be  tried ;  and  if  at  the  end  of  a  week  or  ten  days 
no  bad  effects  are  observed,  three  tabloids  daily  may  be  pre- 
scribed. If  no  effect  is  produced  in  a  month  its  employment 
should  be  abandoned.2  The  same  authority  praises  highly 
salicylate  of  sodium  or  salicin,  especially  in  acute  cases 
where  arsenic  and  thyroid  extract  are  contra-indicated. 
The  dose  given  is  15  gr.  three  times  a  day,  for  an  adult, 
of  the  sodium  salt,  or  15  to  20  gr.  or  more  of  the  salicin. 
In  our  opinion  the  salicin  is  preferable,  since  salicylate  of 
sodium  in  large  doses  may  set  up  an  albuminuria. 
These  drugs  are  not  apt  to  be  beneficial  in  limited 
chronic  patches  with  but  little  hyperemia. 

Crocker  also  recommends  3  to  5  gr.  of  quinine  dissolved 
in  the  acid  portion  of  an  effervescing  citrate  of  potassium 
solution  in  widespread,  inflammatory  conditions  of  psoriasis. 

The  local  treatment  of  psoriasis  is  of  especial  impor- 
tance ;  indeed  arsenic  and  such-like  remedies  produce  in  an 
indirect  way,  and  by  a  circuitous  route,  the  same  changes 
in  the  skin  that  come  from  the  local  application  of  the  tars 
and  other  topical  stimulants.  The  first  thing  to  be  done 
in  all  cases  is  to  remove  the  scales  thoroughly,  so  that  the 
remedy  may  come  in  direct  contact  with  the  diseased  sur- 
face. Where  larger  surfaces  are  involved,  alkaline  warm 
baths  (carbonate  of  potash  or  soda,  4  or  5  oz.,  to  water, 
30  gal.),  preceded  by  frictions  with  green  soap,  and  fol- 
lowed by  inunctions  with  vaselin,  serve  the  purpose  very 

1  Twentieth  Century  Pract.  Med.,  p.  275. 

2  Thyreoidin  may  be  used  instead. 


144  INFLAMMATIONS 

well  and  are  in  themselves  curative.     In  general  acute 
cases  the  soap  frictions  should  be  omitted. 

The  scales  may  be  removed  from  localized  patches  with 
soft  soap  and  a  nail-brush.  The  following  solution  of 
salicylic  acid  may  also  be  rubbed  in  with  advantage : 

1$ — Acidi  salicylic! 5j 

Alcoholis 5iv — M. 

The  following  salve,  recommended  by  Jamieson,  is  also 
efficacious  in  getting  rid  of  the  scales : 

~fy — Ammonii  carb 3ijss 

Lanolini 3vj 

Cerati  Galeni 5jss — M. 

S. — Apply  twice  daily. 

Steam  and  hot-air  baths  are  valuable  for  this  purpose, 
especially  the  latter,  to  which  Stelwagon  ascribes  a  curative 
effect  as  well.  Rubber  gloves  and  sheets  of  Macintosh 
worn  next  the  skin  are  a  great  help  in  severe  cases. 

For  the  direct  local  treatment  of  the  disease  a  large 
array  of  remedies  has  been  proposed,  and  every  day 
witnesses  new  accessions  to  the  list.  We  shall,  however, 
direct  attention  only  to  those  that  have  proved  most  c-ilica- 
cious  in  our  own  experience.  In  acute,  generalized  forms 
of  the  disease,  warm  alkaline  baths,  followed  by  inunctions 
with  vaselin,  not  only  remove  the  scales,  but  sometimes 
cause  the  disappearance  of  the  eruption.  Mopping  with 
the  zinc  and  calamine  lotion  also  relieves  the  hyperemia. 
For  chronic  cases  and  more  or  less  limited  patches,  chrys- 
arobin  is  undoubtedly  the  best  remedy.  Although  it  has 
many  objectionable  features,  we  believe  that  in  suitable 
cases,  and  in  proper  situations,  it  removes  the  eruption 
more  speedily  than  anything  else. 

It  may  be  employed  as  an  ointment,  or  in  the  shape  of 
a  paint.  An  ointment  made  with  lanolin  or  vaselin  gives 
the  best  results.  We  prefer  this  formula: 

1$ — Chrysarobini oss 

Ung.  aq.  rosir 5ij 

Lanolini ovj — M. 

S. — Local  use. 


PSORIASIS  145 

Frictions  made  with  this  salve  soon  remove  the  eruption, 
but  in  addition  to  irremediably  spoiling  the  underclothing 
it  occasions  more  or  less  dermatitis,  thereby  necessitating 
its  discontinuance.  For  this  reason  the  pigments  made  with 
collodion  or  traumaticin  are  to  be  preferred,  although 
they  also  have  in  a  less  degree  the  same  objectionable 
features.  The  preparation  advocated  by  G.  H.  Fox  is 
made  in  this  way: 

1$ — Chrysarobini gr.  xlviij 

Acidi  salicylic! gr.  xlviFj 

^Etheris 5j 

Collodii  flex q.  s.  ad  5j — M. 

As  a  rule  we  order  the  pigment  made  with  the  solution 
of  gutta-percha,  after  Auspitz's  method : 

T$ — Chrysarobini gr.  xxx-xlviij 

Acidi  salicylici gr.  xxx-xlviij 

Traumaticini 5j — M. 

S. — Apply  with  camel's-hair  pencil  every  fourth  night;  then  take 
a  warm  bath  and  reapply  the  remedy. 

Besnier  recommends  that  a  15  per  cent,  solution  of 
chrysarobin  in  chloroform  be  first  painted  over  the  erup- 
tion with  a  stiff  brush,  which,  when  dry,  is  to  be  followed 
by  a  varnish  of  traumaticin.1  In  a  few  days  after  the 
application  of  any  one  of  these  pigments  the  coating  begins 
to  peel  off;  this  should  be  facilitated  by  a  warm  bath,  after 
which  another  application  may  be  put  on. 

Chrysarobin  should  not  be  used  on  the  face,  scalp,  about 
the  privates,  or  where  the  skin  is  very  thin.  If  very  much 
dermatitis  is  set  up,  the  chrysarobin  should  be  discon- 
tinued, and  only  renewed  after  its  subsidence,  in  the 
mean  time  mopping  on  the  calamine  and  zinc  lotion.  If  the 
drug  is  going  to  prove  of  benefit  its  good  effects  are  mani- 
fested in  a  few  days.  It  should  be  kept  up  until  the  patches 
are  quite  free  of  scales.  The  appearances  left  behind 
after  the  use  of  chrysarobin  are  quite  characteristic,  the 

1  Traumaticin  is  a  10  per  cent,  solution  of  gutta-percha  in  chloro- 
form. 

10 


1 46  I  NFL  AM  MA  TIONS 

former  areas  of  disease  remaining  for  a  season  preternat- 
urally  white,  while  the  surrounding  integument  is  deeply 
discolored. 

Pyrogallic  acid  in  ointment,  or,  better,  in  pigment 
(1  drachm  to  1  oz.),  is  somewhat  slower  in  its  action  than 
the  chrysarobin,  but  it  is  cleaner,  and  were  it  not  that 
it  cannot  be  used  over  too  large  surfaces,  on  account  of 
toxic  effects  sometimes  ensuing,  it  would  in  many  cases 
largely  take  the  place  of  the  former. 

In  former  years  tar  was  the  chief  remedy  in  psoriasis, 
and  it  is  still  regarded  very  favorably  by  many. 

It  may  be  used  in  the  form  of  the  official  ointment,  or 
as  the  oleum  cadini  or  oleum  rusci,  variously  diluted  or 
pure.  We  have  generally  used  the  tincture  of  green  soap 
with  tar. 

1$ — Saponis  olives  praep., 

Olei  rusci, 

Alcoholis aa     5j — M. 

S. — Rub  firmly  into  the  patches  twice  a  day. 

Greenough  suggests  the  following  as  an  eligible  formula 
in  private  practice : 

1^ — Olei  cadini, 
Glycerini, 
Alcoholis aa     5j — M. 

Tar  may  also  be  prescribed  in  the  form  of  an  alcoholic 
tincture,  or  the  liquor  carbonis  detergens  and  the  liquor 
picis  alkalinus,  pure  or  diluted,  may  be  painted  over  the 
eruption. 

Sulphur  sometimes  acts  very  well  in  comparatively  mild 
cases.  We  generally  order  it  combined  with  salicylic  acid. 

1} — Acidi  salicylic! 9j-oss 

Sulphuris  proecip 5jss 

Vaselini 5j— M. 

S. — Rub  in  thoroughly  twice  a  day. 

In  the  modified  Wilkinson's  ointment  we  get  the  benefit 
of  both  tar  and  sulphur: 


PSORIASIS  147 

I$— Sulphuris  sublimati, 

Olei  cadini aa     5iv 

Saponis  viridis, 

Acupis aa     5j 

Cretse  praep oijss — M 

This  preparation  is  of  especial  value  in  much  infiltrated 
plaques.  The  Vleminckx's  solution,  pure  or  variously 
diluted,  is  useful  in  a  similar  condition  of  affairs. 

Among  other  remedies  of  more  or  less  efficacy  may  be 
mentioned  thymol,  turpentine,  creosote,  naphthol,  anthra- 
robin,  and  the  mercurials.  Eugallol  is  highly  esteemed  by 
Kromayer.  It  is  applied  as  a  paint,  once  daily,  and  when 
dry  the  part  may  be  dusted  with  zinc  oxide. 

What  has  been  said  above  in  regard  to  the  treatment  of 
psoriasis  refers  more  especially  to  the  disease  as  it  exists 
on  the  general  surface,  but  occurring  on  the  face,  scalp, 
hands,  or  feet,  the  method  of  procedure  must  be  somewhat 
modified.  Psoriasis  on  the  face  is  best  treated  by  the 
white  precipitate  salve : 

1$ — Hydrarg.  ammoniati gr.  xx-3j 

Ung.  aq.  rosae 5 — M. 

S. — Local  use. 

A  paste  is  usually  more  agreeable  and  equally  beneficial ; 

1$ — Hydrarg.  ammoniati gr.  xx-3ss 

Zinci  oxidi 5ss 

Pulv.  amyli 5ij 

Vaselini 5j — M. 

S. — Apply  in  thin  layer  to  eruption. 

The  mercurial  should  not  be  applied  over  too  large  a 
surface  at  a  time,  for  fear  of  absorption. 

The  sulphur  and  salicylic  acid  ointment  is  also  useful 
here.  On  the  scalp  the  scales  should  be  first  washed  out 
with  the  tincture  of  green  soap,  after  which,  according  to 
circumstances,  may  be  applied  some  preparation  of  tar, 
mercury,  or  sulphur.  Among  the  efficient  preparations 
for  this  purpose  are  the  following: 

J^ — Liq.  carbonis  deterg 5j 

Hydrarg.  ammoniati oss 

Yast'lini 3j — M. 

S. — Apply  to  scalp. 


148  INFLAMMATIONS 

1$ — Olei  rusci oj 

Glycerin! oij 

Alcoholis q.  s.  ad     3vj 

Olei  rosae q.  s. — M. 

S. — Apply  with  medicine  dropper  and  rub  in  thoroughly. 

The  sulphur  and  salicylic  acid  salve  already  mentioned 
is  also  beneficial.  Psoriasis  of  the  palms  and  soles  may 
be  treated  with  much  satisfaction  by  applications  of  the 
compound  salicylated  soap  plaster  spread  on  muslin,  as 
well  as  by  the  pigment  of  chrysarobin  and  salicylic  acid. 
Since  in  many  cases  psoriasis  is  either  greatly  better  or 
entirely  disappears  in  summer,  it  is  natural  to  presume 
that  residence  in  a  warm,  equable  climate  would  prove 
beneficial  in  the  disease;  and  as  a  matter  of  fact  this 
presumption  is  justified  by  experience. 

Hyde  and  Montgomery  prescribe  sun-baths  in  psoriasis, 
and  Stelwagon  recommends  the  arc-light  for  the  same 
purpose.  Pospelow  obtained  great  improvement  in  a  case 
of  psoriasis  of  the  nails  of  five  years'  standing,  after  a 
few  light  baths,  together  with  paintings  of  a  5  per  cent, 
chrysarobin  traumaticin. 

Holzknecht  obtained  disappearance  of  patches  with  one- 
minute  applications  of  radium  of  high  activity. 

Oudin,  Williams,  and  Grube  highly  recommend  high- 
frequency  currents.  Allen  says  they  ease  the  itching  and 
cause  disappearance  of  recent  patches. 

The  general  consensus  of  opinion  as  to  the  use  of  the 
x-ray  may  be  stated  under  the  following  heads : 

1.  The  oxray  is  not  recommended  for  routine  use  in  pso- 
riasis, but  only  for  cases  which  resist  the  usual  methods. 

2.  It  finds  its  chief   use  in   the   treatment  of  chronic 
isolated  patches,  as  at  the  knees,  elbows,  and  sacrum. 

3.  In  such    cases  it  generally    gives   very  satisfactory 
results  as  far  as  the  removal  of  lesions  is  concerned. 

4.  The  tendency  to  recurrence  is  nowise  lessened  by  this 
treatment;  some,  indeed,  think  it  is  enhanced. 

5.  The  ray  acts   in  the  same  manner  as  topical  appli- 
cations of  the  chrysarobin  class,  that  is,  by  exciting  leuko- 
cytosis. 


PSORIASIS  149 

6.  An  early  favorable  sign  is  the  disappearance  of  the 
familiar  punctate  bleeding  on  erasion. 

7.  An  area  of  pigmentation  often  persists  for  some  weeks, 
sharply  margined  at  the  border  of  the  patch,  and  gradually 
fading  into  the  surrounding  healthy  skin. 

Williams  gives  from  6  to  10  exposures  on  alternate  days. 
Startin  succeeded  in  an  inveterate  case  with  3  exposures 
at  intervals  of  three  days.  Scholtz  repeats  irradiation  daily 
for  some  three  days,  then  every  other  day,  and  later 
every  three  days,  giving  ten-minute  sittings  at  21  inches. 
Holzknecht,  Kienbock  and  Belot  use  single  sittings,  the 
latter  sometimes  two.  The  dose  advised  varies  from  3 
to  6.  H.  Belot,  with  an  anticathode  at  5  inches,  gives 
a  fifteen -minute  sitting  one  day,  with  one  of  five  or  ten 
minutes  the  next.  In  multiple  foci,  Kienbock  uses  a  dis- 
tance of  12  inches  for  three  minutes  without  shielding. 
Stelwagon,  using  a  £-  to  2-inch  tube  at  6  to  12  inches 
distance,  moves  it  about  from  place  to  place,  allowing  the 
ray  to  play  from  three  to  ten  minutes  on  one  region,  pro- 
gressing cautiously  from  the  shorter  to  the  longer.  Two 
to  three  times  a  week  is  sufficient.  Dermatitis  should  be 
avoided.  Allen  recommends  a  preliminary  removal  of  the 
scales. 

Finally,  it  may  be  said  that  the  o>ray  is  especially  valu- 
able in  psoriasis  of  the  nails. 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Acidi  salicylici 3ijss 

Chrysarobini, 

Olei  rusci aa     3v 

Saponis  viridis, 

Vaselini aa     ovj 

Dreuw. 

1$ — Chrvsarobi  n  i , 

Ichthyolis fiti     gr.  xx 

Acidi  salicylici gr.  viij 

Ung.  zinci  oxidi gr.  c.c. 

Vaselini q.  s.  ad     5j — M. 

Unna. 


150  INFLAMMATIONS 

1$ — Chrysarobini , 

Liq.  carbonis  deterg., 

Hydrargyri  ammon aa      gr.  x 

Adipis  benzoati 5j — M. 

S. — Remove  scales  and  rub  in  for  one-half  hour.     Leave  salve  on 
all  night.    Bath  in  morning.  Hutchinson. 

1$ — Acidi  pyrogallici gr.  x-xl 

Acidi  salicylici gr.  x 

Athens 3j 

Olei  ricini n\v 

Collodii q.  s.  ad  5j — M. 

S. — Paint  on  parts  once  every  two  or  three  days.  Stel wagon. 

1$ — Thymolis gr.  xv-5iij 

Vaselini Bj — M. 

Crocker. 

1^— Pulv.  naphthplis 5jss 

Saponis  viridis 5v 

Cretse  praep 5j 

Adipis 5x — M. 

Kaposi. 


PITYRIASIS  MACULATA  et  CIRCINATA. 

Description. — This  affection,  which  is  also  called  pityria- 
sis  rosea,  was  originally  described  by  Gibert,  but  Duhring 
was  the  first  in  recent  years  to  redirect  attention  to  it. 

Brocq  states  that,  anticipating  the  general  eruption  by 
from  four  to  fifteen  days,  there  appears  about  the  waist, 
neck  or  arms,  a  single  patch.  This  patch  is  oval  or  circular, 
its  edges  are  of  a  bright  red,  and  it  is  a  little  elevated  and 
covered  with  delicate  scales.  Subsequently,  and  more  or 
less  suddenly,  a  great  number  of  patches  make  their  appear- 
ance, and  the  whole  body,  with  the  exception  of  the  hands 
and  feet,  may  be  affected,  but  the  sites  of  predilection  are 
the  upper  portions  of  the  trunk. 

The  eruption  presents  two  apparently  distinct  types: 
the  macular  type,  consisting  of  small  pin-head  to  pea-sized 
lesions,  rosy-red  in  color,  not  clearly  defined,  and  having  a 
scaly  surface;  the  other,  or  circinate,  form  possessing  a 


PITYRIASIS  MACULATA  ET  CIRC  IN  AT  A         151 

rounded  or  oval  outline  and  a  well-defined  border,  which 
may  attain  a  diameter  of  from  ^  to  1  inch. 

The  larger  patches  are  developed  from  the  small  pri- 
mary lesions,  and  in  many  instances  they  undergo  a  central 
involution,  and  present  red  and  scaly  peripheral  rings  and 
characteristic  "parchment-like"  centres. 

In  course  of  time  these  rings  become  broken,  and  by 
the  coalescence  of  segments  of  other  circles  various  gyrate 
figures  may  be  formed.  Many  of  the  lesions,  however,  do 
not  pass  through  the  same  stages  of  development,  and  as  a 
consequence  the  different  forms  mentioned  above  may  be 
present  at  the  same  time. 

Subjective  symptoms  are  not  marked,  and  consist 
mainly  of  slight  burning  or  itching.  The  disease  is  self- 
limited,  tending  to  spontaneous  recovery  in  from  two 
weeks  to  as  many  months. 

Etiology. — The  etiology  of  the  disease  is  obscure.  It  is 
sometimes  observed  to  be  quasi-epidemic,  and  occasionally 
two  members  of  a  family  may  be  affected.  Pityriasis  rosea 
should  be  differentiated  from  ringworm,  seborrhea,  and 
especially  syphilis. 

Prognosis. — This  is  invariably  good. 

Treatment. — Internal  remedies  are  not  required,  although 
Crocker  believes  that  10  or  15  gr.  of  salicin,  three  times  a 
day,  shortens  the  duration  of  the  disease. 

If  itching  is  a  prominent  symptom,  the  zinc  and  calamine 
lotion,  with  a  few  drops  of  carbolic  acid  to  the  ounce,  will 
readily  allay  it.  Hyde  and  Montgomery  recommend  the 
following  plan  of  treatment:  The  patient  takes  a  bath  at 
night,  and  after  drying  the  skin  applies  to  the  eruption  a 
weak  vinegar  or  dilute  acetic  acid  lotion;  before  this 
application  is  quite  dry  a  10  to  15  per  cent,  solution  of 
sodium  hyposulphite  is  mopped  on,  which  is  followed  in 
turn  by  a  simple  dusting  powder.  The  same  authors  have 
seen  abatement  of  subjective  symptoms  and  prompt  invo- 
lution of  the  lesions  follow  brief  exposures  to  o>rays. 

The  most  generally  successful  treatment  is  that  of 
Jamieson,  as  given  by  Norman  Walker  in  his  excellent 


152  INFLAMMATIONS 

text-book,  viz.,  the  patient  should  be  soaked  daily  for  half 
an  hour  in  a  bath  to  which  two  or  three  teaspoonfuls  of 
Condy's  fluid  (sodium  permanganate  1,  water  500),  have 
been  added,  after  which  a  3  to  5  per  cent  salicylic  vaselin 
is  freely  applied  to  the  skin. 


DERMATITIS  EXFOLIATIVA. 

Description. — In  a  general  way  exfoliative  dermatitis 
may  be  defined  as  an  acute  or  chronic,  general  or  partial, 
cutaneous  inflammation,  in  which  the  epidermis  is  freely 
shed  in  large  or  small  scales. 

The  following  clinical  forms  represent  the  disease  suffi- 
ciently from  the  standpoint  of  therapeutics. 

Relapsing  Scarlatinifonn  Erythema. — A  description 
of  this  disorder  has  already  been  given  (p.  20)  and  need 
not  be  repeated  here. 

Acute  Exfoliative  Dermatitis. — Although  often  prim- 
ary, this  disorder  may  follow  generalized  psoriasis,  lichen, 
eczema,  or  the  application  of  irritating  drugs.  The  involve- 
ment of  the  skin  is  at  first  local — in  one  of  our  cases  begin- 
ning as  a  red  patch  at  the  pit  of  the  stomach^-but  more  or 
less  quickly  the  whole  integument  may  be  implicated. 
The  skin  is  at  first  free  from  scales,  and  may  be  bright  red, 
violaceous,  or  of  a  dusky  hue.  There  is  some  degree  of 
pruritus.  In  a  few  days  the  cuticle  begins  to  desquamate 
in  large  or  small,  thin,  papery  scales.  The  character  of  the 
desquamation  is  influenced  by  situation;  on  the  scalp  it  is 
furfuraceous,  on  the  body  and  upper  portion  of  the  extremi- 
ties the  scales  are  generally  large  and  more  or  less  imbri- 
cated, while  from  the  hands  and  feet  we  have  seen  the 
epidermis  shed  in  great,  thick,  glove-like  pieces.  The  hair 
is  shed  in  the  course  of  the  disease,  sometimes  even  the 
beard,  eyelashes,  and  pubic  growth;  the  nails  are  also 
lost.  The  mucous  membranes  may  also  participate  in 
the  general  process.  Some  cases  are  complicated  by  an 
ephemeral  eruption  of  vesicles,  blebs,  or  pustules.  In 


DERMATITIS  EXFOLIATIVA  153 

severe  cases  the  general  state  of  the  patient  may  excite 
much  apprehension,  either  from  the  extreme  emaciation 
and  debility  present,  or  from  the  existence  of  serious  com- 
plications. The  affection  may  last  from  two  to  three  weeks 
to  as  many  months.  Undoubtedly,  there  are  much  milder 
grades  of  exfoliative  dermatitis  than  the  one  just  described. 
There  are  also  local  forms. 

Chronic  Exfoliative  Dermatitis,  or  Pityriasis  Rubra.— 
According  to  Hebra  and  others,  pityriasis  rubra  is  a  dis- 
ease sui  generis.  As  in  the  acute  form,  the  disorder  begins 
in  one  or  more  localized  patches.  These  coalesce  and 
gradually  invade  the  whole  body.  The  skin  may  be  of  a 
dark  or  vivid  red,  or  bluish  red.  The  desquamation  is  very 
free;  the  scales  are  thin  and  papery  on  the  general  surface, 
imbricated,  and  from  a  line  to  an  inch  or  more  in  diameter. 
When  the  integument  is  freed  of  the  scales,  it  has  a  shining, 
tense  appearance.  The  skin  is  not  infiltrated  as  a  rule, 
and  there  is  no  moisture.  There  may  be  edema  of  the 
lower  limbs.  Alopecia  and  exfoliation  of  the  nails  also 
occur.  The  patient  complains  but  little  of  itching,  but  his 
skin  feels  too  small  for  him,  and  he  is  apt  to  be  chilly,  even 
in  the  warmest  weather.  Febrile  exacerbations  occur  now 
and  again.  The  disease  lasts  months  or  years;  there  is 
generally  a  fatal  termination,  either  due  to  progressive 
emaciation  and  consequent  exhaustion,  or  else  the  patient 
is  carried  off  by  some  intercurrent  affection. 

Etiology. — The  causes  of  so  complex  a  disorder  as  exfoli- 
ative dermatitis  are  various  and  it  must  be  confessed,  for 
the  most  part,  obscure.  We  often  recognize  the  clinical 
condition  as  following  upon  psoriasis  or  eczema,  and  as 
the  result  of  the  irritating  effects  of  drugs;  it  has  also  been 
thought  to  occur  in  connection  with  gout  and  rheumatism, 
and  with  tuberculosis.  Sometimes  the  subjects  of  the  dis- 
ease have  had  no  apparent  antecedent  ill-health. 

Treatment. — It  may  be  inferred,  from  what  has  just  been 
said  about  the  etiology  of  exfoliative  dermatitis,  that  there 
can  be  no  special  or  invariable  form  of  internal  treatment 
for  the  disease.  Of  course,  obvious  predisposing  or  exciting 


154  INFLAMMATIONS 

influences  should  be  removed  if  possible,  but  in  the  main 
the  constitutional  treatment  is  symptomatic.  The  acute 
form  is  best  treated  with  diaphoretics  and  diuretics. 
Salicin  in  10-  to  15-gr.  doses  several  times  a  day  is  invalu- 
able in  presumably  septic  cases.  Wine  of  antimony  in 
from  5-  to  7-minim  doses  has  been  recommended.  Crocker 
thinks  highly  of  quinine  given  in  an  effervescing  potash 
mixture  as  follows: 

1$ — Potassii  bicarbonatis 9j 

Aquae  destillatse 3ss — M. 

Solve. 

1$ — Acidi  citrici gr.  xij 

Quininse  sulphatis gr.  iv 

Aquse  destillatse 3ss — M. 

Solve. 

S. — Mix  the  two  and  drink  during  effervescence  every  four  hours. 

It  seems  to  be  definitely  established  that  arsenic  is  with- 
out value  and  is  probably  harmful  in  this  disease. 

Ten  drops  each  of  fluidextract  of  ergot  and  tincture  of 
iron  have  seemed  to  us  to  be  of  some  service  in  chronic 
cases.  When  the  kidneys  are  healthy,  Malcolm  Morris 
gives  opium  internally  for  restlessness  and  sleeplessness 
— a  recommendation  that  we  can  endorse  from  experience. 

Locally,  the  employment  of  soothing  ointments,  lotions, 
and  baths  is  indicated.  Where  it  can  be  properly  carried 
out,  the  following  plan  of  treatment,  which  is  suggested  by 
Mackenzie,  is  by  far  the  most  agreeable  to  the  patient: 
Two  garments  are  made  of  lint — a  jacket  and  trousers, 
with  socks  of  the  same  material  attached.  A  mask  of  lint 
should  be  used  for  the  face  and  head.  This  suit  is  to  be 
kept  constantly  soaked  with  the  following  lotion :  Glycerin 
of  subacetate  of  lead  (B.  P.),  and  pure  glycerin,  of  each 
1  oz.;  water,  to  1  pint.  A  basin  of  the  lotion,  which  in  cold 
weather  may  be  wanned,  should  be  kept  by  the  patient's 
bedside,  so  that  the  fluid  may  be  squeezed  over  the  lint 
suit  as  often  as  desired.  When  the  redness  of  the  skin  is 
lessened  recourse  may  be  had  to  greasy  applicatons,  such 
as  equal  parts  of  vaselin  and  lanolin.  Upon  any  return 
of  the  hyperemia  the  lead  lotion  may  be  again  applied. 


DERMATITIS  EXFOLIATIVA  155 

With  a  certain  number  of  patients  oily  applications  are 
at  all  times  more  agreeable.  The  ordinary  carron  oil  is 
soothing,  and  can  be  made  antipruritic  by  the  addition  of  a 
little  carbolic  acid  or  creosote.  Lassar's  paste,  which  is 
often  recommended,  is  usually  very  annoying  when  it 
becomes  dry,  and  the  same  may  be  said  of  Crocker's  lini- 
ment as  generally  prescribed :  The  following  modification 
is  more  acceptable: 

!$ — Zinci  oxidi 5ss 

Pulv.  calaminsc  pnep 9j 

Liq.  calcis, 

Ol.  amygdalae  dulcis aa  Bj 

Lanolini 5jss — M. 

Carbolic  acid  or  the  liquor  carbonis  detergens  may  be 
added  to  this  preparation.  This  liniment  may  be  gently 
smeared  over  the  affected  surfaces  with  the  fingers,  or  else 
spread  on  strips  of  soft  cloth,  which  in  turn  should  be  kept 
in  place  by  suitable  bandages. 

Baths  at  times  give  considerable  relief,  and  may  be  taken 
daily  if  necessary.  Even  if  baths  have  no  direct  medicinal 
effect,  they  make  the  patient  more  comfortable  by  ridding 
him,  temporarily,  of  the  acrid  accumulations  on  his  skin. 

Mackenzie  gives  the  following  formulae  for  baths  in 
exfoliative  dermatitis : 

Starch,  1  lb.;  bran,  2  to  6  Ibs. ;  linseed,  gelatin,  3  Ibs.; 
gluten  (size),  6  Ibs.;  to  30  gal.  of  water;  or  alkaline  baths, 
such  as  borax,  3  oz. ;  bicarbonate  of  sodium,  2  to  10  oz. ; 
carbonate  of  soda,  2  to  6  oz. ;  to  30  gal.  of  water;  or  a  com- 
pound alkaline  bath,  as  bicarbonate  of  sodium,  6  oz.; 
borax,  1|  oz. ;  water,  to  30  gal.  The  temperature  of  these 
baths  should  be  from  98°  to  100°  F.,  as  may  be  most  agree- 
able to  the  patient.  The  continuous  bath,  as  in  pemphigus, 
lias  sometimes  been  employed. 

Dermatitis  Exfoliativa  Infantum.  Description. — This 
is  a  severe  form  of  exfoliative  inflammation  of  the 
skin,  usually  unattended  by  fever,  which  begins  between 
the  second  and  fifth  weeks  of  life.  The  disease  appears 
first  around  the  angles  of  the  mouth  as  an  erythema,  with 


1 50  INF  LAM  MA  TIONS 

a  tendency  to  the  formation  of  fissures;  then  this  inflam- 
mation extends  to  the  rest  of  the  body.  The  epidermis 
exfoliates  generally  after  some  amount  of  fluid  has  accumu- 
lated beneath  it.  The  disease  is  very  fatal. 

Treatment. — The  treatment  consists  in  keeping  up  the 
nutrition  of  the  child,  and  the  local  use  of  bland  applica- 
tions. 

Dermatitis  Exfoliativa  Epidemica.  Description. — This 
is  a  rare  form  of  disease  first  described  by  Saville,  and  of 
which  a  few  cases  have  been  seen  in  this  country.  The 
skin  lesions  are  represented  at  first  by  an  erythemato- 
papular  rash,  which  is  sometimes  diffused,  or  in  the  shape 
of  blotches,  that  may  be  grouped  or  solitary.  Occasionally 
flat  papules  were  observed  which  extended  after  the  man- 
ner of.  ringworm.  The  initial  symptoms  soon  disappear, 
but  are  quickly  followed  by  new  lesions  that  become 
generalized.  The  second  stage  lasts  from  three  to  eight 
weeks.  In  the  stage  of  subsidence  the  skin  is  left  greatly 
thickened  and  of  a  polished-brown  appearance. 

Treatment. — The  treatment  is  practically  that  of  any 
other  acute  inflammation  of  the  skin,  but  as  a  rule  nothing 
seems  capable  of  shortening  the  course  of  the  disease. 

Crocker  has,  in  a  few  instances,  succeeded  in  abating  an 
attack  by  painting  a  small,  beginning  area  with  iodine. 


PSORIASIFORM  DERMATOSES. 

Description. — Under  the  various  titles  of  parakeratosis 
variegata,  lichen  variegatus,  erythrodermie  pityriasiqnc  en 
plaques,  lichenoid  eruption,  etc.,  writers  have  called  atten- 
tion to  a  comparatively  rare  form  of  skin  disease  char- 
acterized by  disseminated,  variously  sized  lesions,  super- 
ficially seated,  covered  with  thin  scales,  arranged  in  bands 
or  patches,  and,  owing  to  the  enclosure  of  normal  areas  of 
skin,  presenting,  in  most  cases,  a  reticulated  appearance 
of  the  surface.  The  lesions,  which  are  of  a  reddish  or 
brownish  color,  may  occur  on  any  part  of  the  body,  but, 


URTICARIA  157 

perhaps,  prefer  the  trunk  and  limbs,  and  are,  as  a  rule, 
without  marked  subjective  symptoms.  The  disorder  is 
exceedingly  chronic  and  resistant  to  treatment.  It  is 
seemingly  more  common  in  adult  life  than  in  children,  and 
affects  women  more  often  than  men. 

Brocq  divides  these  cases  into  three  classes  under  the 
following  names:  (1)  Parapsoriasis  guttata;  (2)  parapso- 
riasis  lichenoides;  (3)  parapsoriasis  in  patches. 

Treatment. — The  treatment  is  regarded  as  unsatisfac- 
tory, neither  internal  nor  local  measures  proving  of  any 
service.  Strong  preparations  of  pyrogallol  have  been  most 
favorably  regarded.  In  one  case  of  Brocq'srthird  type 
we  secured  a  comparatively  rapid  cure  of  the  disease  by 
frequent  applications  of  a  wash  containing  10  minims  of 
liquor  carbonis  detergens  to  1  oz.  of  calamine-zinc  lotion. 
On  some  obstinate  patches  a  salve  of  20  gr.  of  white  pre- 
cipitate and  1  drachm  of  the  tar  solution  to  1  oz.  of  vaselin 
was  found  valuable. 

URTICARIA. 

Description. — This  common  affection,  vulgarly  called 
nettlerash  or  hives,  is  characterized  by  an  eruption  of 
pomphi  or  wheals.  These  are  somewhat  firm,  more  or  less 
elevated,  evanescent  efflorescences,  varying  in  size  from  a 
pin-head  to  a  hen's  egg  or  larger;  round,  oval,  or  irregular; 
of  a  whitish  to  rosy  color,  and  most  frequently  accom- 
panied by  intense  itching,  tingling,  or  burning.  The 
following  variations  are  noted: 

When  the  lesions  are  distinctly  papular,  as  is  frequently 
the  case  in  children,  the  eruption  is  termed  urticaria  papu- 
losa  or  lichen  urticatus  (Willan),  and  when ,  through  unusual 
abundance  of  the  serous  effusion,  vesicles  and  bulla1  are 
produced,  urticaria  vesiculosa  et  bullosa.  True  hemorrhage 
into  the  wheals  constitutes  urticaria  hemorrhagica,  or  pur- 
pura  urticans.  In  some  persons  the  irritability  of  the 
integument  is  so  great  that  wheals  in  any  shape  or  form 
can  be  artificially  produced  by  the  slightest  mechanical 


1 58  IN  FLAM  MA  TIONS 

irritation,  and  words  or  figures,  drawn  by  the  finger-nail 
or  any  blunt  instrument,  take  on  all  the  characters  of  an 
urticarial  lesion — a  condition  known  as  urticaria  factitia. 
Urticaria  papulosa,  or  lichen  urticatus,  as  already  stated, 
occurs  mainly  in  children. 

The  eruption  produces  an  intense  pruritus,  so  that  in 
some  cases  the  primary  trouble  is  hidden  by  the  secondary 
eczema  or  pustular  dermatitis.  Usually,  however,  the 
only  visible  lesions  are  white  or  pale-red,  small,  scratched 
papules  scattered  over  the  surface.  In  many  cases  the 
urticarial  element  is  not  apparent  at  first  sight.  This  form 
of  urticaria  is  excessively  distressing  and  is  apt  to  keep  up 
for  a  long  period. 

It  is  customary  to  speak  of  acute  and  chronic  urticaria, 
and  this  division  of  the  subject  serves  a  good  purpose  in 
that  it  helps  to  direct  attention  to  the  etiological  factors 
concerned  in  the  production  of  the  disease. 

Acute  Urticaria. — The  rash  may  be  ushered  in  with  con- 
siderable systemic  disturbance,  the  temperature  running 
up  several  degrees  (urticaria  febrilis);  or  there  may  be  a 
day  or  two  of  malaise  before  the  eruption  makes  its  appear- 
ance, the  symptoms  of  gastric  disturbance  being  well 
marked.  Urticaria  of  this  type  may  persist  for  a  number  of 
days,  being  the  source  of  much  local  and  even  general 
distress.  On  the  other  hand,  a  copious  eruption  of 
wheals  may  make  its  appearance  suddenly  and  without 
premonition  of  any  sort,  and  after  a  longer  or  shorter 
period  as  suddenly  disappear.  Undoubtedly  the  mucous 
membranes  may  also  be  involved  in  the  urticarial  process 
and  give  rise  to  severe  internal  disturbances  involving  the 
stomach,  bowels,  and  respiratory  tract. 

Edema  of  the  glottis  with  fatal  results  may  also  occur. 

Chronic  Urticaria. — In  chronic  urticaria  the  eruption 
comes  and  goes  during  a  long  period  of  time.  These 
periods  of  outbreak  are,  as  a  rule,  quite  irregular,  although 
cases  have  been  observed,  probably  of  malarial  origin,  in 
which  the  nettlerash  displayed  a  marked  periodicity.  The 
lesions  are  not  apt  to  be  as  widespread  or  numerous  as  in 


URTICARIA  159 

the  acute  form.  One  of  us1  observed  a  case  of  chronic 
urticaria  in  which  the  wheals  were  limited  strictly  to  the 
feet  and  hands,  and  during  the  entire  period  of  its  existence 
— several  years — it  never  travelled  beyond  those  parts. 
Urticaria  papulosa  of  children  is  a  typical  example  of  the 
disease  in  its  chronic  and  relapsing  form.  Closely  allied 
to  urticaria  is  the  condition  called  dermatographism,  or 
autographism.  It  is  a  state  of  potential  irritability  of  the 
skin  encountered  in  a  number  of  different  and  diverse 
disorders,  such  as  affections  of  the  brain  and  spinal  cord, 
heart  affections,  rheumatism,  hysteria,  etc. 

Etiology. — Urticaria  is  due  to  various  direct  and  indirect 
causes  acting  upon  the  vasomotor  system.  The  wheal  is 
brought  about  in  all  likelihood  by  a  spasmodic  contrac- 
tion of  the  capillaries,  which  in  turn  is  followed  by  paresis 
and  the  consequent  production  of  a  localized  edema  from 
serous  exudation.  The  exciting  agencies  are  very  numer- 
ous, and  may  be  of  central,  peripheral,  or  reflex  character. 

Among  the  local  causes  of  urticaria  may  be  mentioned 
irritants  of  all  sorts,  such  as  the  bites  of  insects,2  coarse 
flannels,  certain  vegetable  substances,  the  local  application 
of  electricity,  etc. 

The  indirect  causes  are  infinitely  more  numerous,  and 
somewhat  difficult  to  classify. 

Derangement  of  the  gastro-intestinal  tract  occupies 
above  all  the  first  place  in  the  etiology.  Here  we  find  that 
foods  and  medicines  of  many  kinds,  or,  perhaps,  of  any 
kind  under  certain  circumstances,  may  give  rise  to  urti- 
caria. Among  the  first  named  may  be  especially  mentioned : 
shell-fish,  pork,  oatmeal,  pastry,  buckwheat,  and  straw- 
berries; and  among  the  latter,  preparations  of  cinchona, 
copaiba,  and  cubebs.  Intestinal  worms  often  excite  the 
disease  in  children,  and  malaria  may  evoke  a  decidedly 
intermittent  type  of  nettlerash. 

Attention  has  been  called  to  the  fact  that  urticaria  may 
occur  after  puncture  of  an  echinococcus  cyst.  The  chronic 

1  Hardaway. 

2  Hutchinson.    Lichen  urticaria. 


160  INFLAMMATIONS 

forms  of  the  disease  are  observed  in  connection  with  various 
disorders  of  the  male  and  female  sexual  apparatus,  in 
affections  of  the  stomach,  bowels,  kidneys,  and  liver;  also 
as  depending  upon  various  disturbances  of  the  brain  and 
spinal  cord,  and  in  alternation  with  attacks  of  asthma. 
Hirschberg  has  pointed  out  the  frequent  coincidence  of 
hyperchlorhydria  with  urticaria.  Paramore  demonstrated 
by  Wright's  oxalic  acid  test  the  existence  of  a  diminished 
coagulability  of  the  blood  (deficiency  in  calcium  salts) 
in  certain  cases. 

Prognosis. — Acute  urticaria  is  readily  recovered  from 
when  the  offending  cause  is  removed.  In  chronic  cases 
the  prognosis  should  be  guarde.d,  as  it  is  sometimes  very 
difficult  to  discover  and  eradicate  the  exciting  influence. 
Occasionally  urticaria  is  fatal  from  edema  of  the  glottis. 

Treatment. — In  all  cases  the  cause  must  be  ascertained 
and  removed  if  possible.  Mild  outbreaks  often  pass  away 
without  any  special  treatment  beyond  relieving  the  local 
distress.  Acute  attacks  are  generally  due  to  gastric  dis- 
turbance from  irritating  foods,  etc.,  and  when  severe  the 
stomach  must  fc>e  emptied  by  emetics,  and  castor  oil  or 
some  other  mild  aperient  given. 

Sometimes  such  a  condition  will  persist,  being  kept  up 
by  repeated  exacerbations,  for  a  number  of  days,  and  pro- 
duce a  condition  of  mind  and  body  hardly  short  of  agoniz- 
ing. In  such  instances  the  state  of  the  mucous  surfaces  is 
prehaps  closely  allied  to  that  seen  on  the  skin,  and  the 
treatment  should  consist  of  soothing  substances  like  bis- 
muth combined  with  magnesium  carbonate.  At  the  same 
time  alkaline  mineral  waters  should  be  taken  copiously. 
The  diet  should  be  bland  and  unirritating.  In  the  majority 
of  cases  of  recurrent  urticaria  it  will  be  found  that  some 
article  of  food  of  drink  is  at  the  bottom  of  the  mischief; 
consequently,  whatever  is  obnoxious  in  this  respect  should 
be  ferreted  out.  Indeed,  in  treating  chronic  urticaria  it 
must  be  constantly  remembered  that,  under  certain  cir- 
cumstances of  idiosyncrasy,  the  disease  may  be  set  up  by 
the  most  various  and  diverse  causes,  and  in  intractable 


URTICARIA  161 

cases  the  physician  must  carefully  study  the  history, 
health,  and  habits  of  each  patient.  The  main  lines  of  this 
investigation  are  indicated  under  etiology.  When  dimin- 
ished coagulability  of  the  blood  can  be  shown,  as  indicated 
above,  the  calcium  salts  should  be  administered.  Wright 
strongly  advises  the  chloride;  20  gr.  well  diluted  may  be 
given  after  meals,  which  may  be  increased  to  40  gr.  or 
more.  It  should  be  continued  a  long  time. 

Generally  success  will  attend  judicious  efforts  made  in 
these  directions,  but  unfortunately  there  will  remain  a 
residuum  of  cases  that  are  apparently  without  cause.  In 
such  instances  we  must  resort  to  empirical  remedies. 
C.  Heitzmann  has  spoken  well  of  ergot  in  full  doses,  and  we 
have  occasionally  seen  it  succeed.  Belladonna  and  atropia 
may  be  tried  in  appropriate  doses.  Among  other  remedies 
may  be  mentioned  quinine,  iodide  of  potassium,  and  salicy- 
late  of  sodium  or  strontium.  Pilocarpine  hypodermically 
or  by  the  mouth  is  sometimes  valuable.  Antipyrine  and 
phenacetin  will  give  temporary  relief.  Wine  of  antimony 
in  5-drop  doses  often  does  good.  Ichthyol  internally  in  the 
dose  of  from  2  to  6  gr.,  three  times  a  day,  often  acts  well. 
It  is  best  given  in  pill  or  capsule. 

Lotions  of  soda  and  water,  vinegar,  pure  or  diluted, 
brandy,  whisky,  cologne,  alcohol,  etc.,  are  all  well  known 
and  often  useful  domestic  remedies  for  local  application. 
Carbolic  acid  is  probably  the  best  antipruritic  agent  in 
our  possession.  It  is  generally  mopped  on  the  surface  in 
the  form  of  a  lotion,  but  we  think  it  is  very  much  more 
efficacious  if  sprayed  on  through  an  atomizer: 

1$ — Acidi  carbolici 3jj-iv 

Glycerin! 3j 

Aquae q.  s.  ad  5xvj — M. 

S. — Use  as  a  spray. 

To  increase  the  effect  5  to  10  drops  of  the  oil  of  pepper- 
mint may  be  added  to  each  atomizerful  of  the  preparation. 

The  liquor  picis  alkalinus  and  liquor  carbonis  detergens 
may  also  be  used,  in  the  same  strength  as  the  carbolic  acid, 
in  the  form  of  a  spray. 
11 


162  INFLAMMATIONS 

The  often-quoted  calamine  and  zinc  preparation  is  also 
very  valuable  as  a  lotion,  combining  with  it  a  small  quan- 
tity of  carbolic  acid: 


$ — Acidi  carbolici    . 
Zinci  oxidi    . 
Pulv.  calaminse  prsep. 
Glycerin! 
Liq.  calcis 


3J 

3  88 

9iv 

5i 

5vij— M. 


S. — Mop  on  freely. 

Menthol  combined*  with  carbolic  acid  will  afford  relief, 
at  least  temporarily: 

1$ — Mentholis 5ij 

Alcoholis q.  s. 

Acidi  carbolici 3ss 

Lotionis  zinci  oxidi  comp 3vj — M. 

S. — Mop  on  with  soft  rag. 

Among  other  remedies  of  this  class  are  to  be  noted  a 
solution  of  benzoic  acid  (5j~5xvj);  menthol  in  solution 
with  alcohol  and  water  (fy — Mentholis,  gr.  xxx-^ij;  gly- 
cerini,  §ss;  alcoholis,  3JSS>  aquae,  q.  s.  ad  5jv — M.); 
thymol  (gr.  j~5j)  and  borax  (gr.  v-§j). 

Bromokoll  in  a  10  or  20  per  cent,  paste  or  salve  has  been 
highly  recommended  as  an  antipruritic,  but  we  have  had 
no  great  amount  of  satisfaction  from  its  use. 

Ointments  sometimes  give  relief  when  lotions  fail.  For 
limited  eruptions  chloral  and  camphor  (1^ — Camphora*, 
chloralis,  aa  3ss-3j;  unguentum  aquse  rosae,  5j — M.)  or 
menthol  (1$ — Mentholis,  gr.  x~3j;  vaselini,  5j)  may  be 
employed.  Tar  in  salve  form  is  beneficial,  but  dirty.  A 
soft,  cream-like  preparation  recommended  by  Macintosh 
in  eczema  is  equally  serviceable  in  urticaria : 

~fy — Bismuthi  subnitratis 3ij 

Zinci  oxidi 3ss 

Glycerini 3jss 

Acidi  carbolici  liq nptx-xxx 

Vaselini 5vj — M. 

S. — :Apply  with  fingers  or  brush. 

Baths,  both  acid  and  alkaline,  may  be  administered  in 
certain  cases.  Bulkley  suggests,  in  chronic  cases,  a  bath 


URTICARIA  P1GMENTOSA  163 

containing  carbonate  of  potassium,  §viij;  carbonate  of 
sodium,  §vj;  borax,  §iv.  Of  these  ingredients  take  from 
two  to  four  teaspoonfuls  with  an  equal  quantity  of  starch  to 
each  gallon  of  water.  After  the  bath,  when  the  body  is 
dry,  the  surface  should  be  anointed  with  carbolated  cosmo- 
line.  Galvanic  and  faradic  electricity  often  give  marked 
relief.  Gregor  reports  a  case  of  two  years'  standing  cured 
by  six  applications  of  the  high-frequency  effleuve  and  con- 
densation couch.  In  persistent,  recurring  cases,  Allen 
recommended  general  effluviation  with  a  pointed,  metallic 
electrode. 

ADDITIONAL  PRESCRIPTIONS. 

1$  —  Bismuth!  subcarbonatis     ......     gr.  x 

Magnesii  carbonatis      .......     gr.  v  —  M. 

Ft.  chart.  No.  j. 

S.  —  One  powder  after  meals  and  at  bedtime.    For  acute  cases. 


1$  —  Cerii  oxalatis      ......... 

Bismuthi  subcarbonatis     ...... 

Magnesii  carb.  levis       .......      5iv  —  M. 

S.  —  Even  teaspoonful  in  water  between  meals  and  at  bedtime.  In 
urticaria  due  to  hyperacidity. 

1$  —  Eau  de  Cologne         ........  3ij 

Zinci  oxidi     ..........  3ss 

Liq.  carbon,  deterg  ........  5ss 

Aquae  destillatae  ........  Sxvij  —  M. 

S.  —  Apply  with  a  brush  or  rag  and  allow  to  dry.  Whitla. 

~fy  —  Calcii  lactatis     .........     gr.  xxx 

Aquae  anisi         .........     oij  —  M. 

S.  —  To  be  taken  at  once.  In  cases  when  attack  is  due  to  eating 
sour  fruit.  Whitfield. 

URTICARIA  PIGMENTOSA. 

Description.  —  Urticaria  pigmentosa  (xanthelasmoidea, 
Fox)  is  a  rare  type  of  urticaria  and  differs  in  many  par- 
ticulars from  the  forms  just  described.  It  begins  within 
the  first  six  months  and  occasionally  within  the  first  few 
days  of  life,  although  Elliot  reports  a  case  that  did  not 
begin  until  the  twenty-seventh  year.  The  first  evidence 
of  the  disease  is  the  eruption  of  reddish-yellow  wheals, 


164  INFLAMMATIONS 

which  may  either  disappear  and  leave  in  their  stead 
dark-brown  or  black  macules,  or  they  may  remain  in- 
definitely as  yellowish-brown  nodules.  At  times  the 
lesions  are  complicated  with  vesicating  apices,  or  even 
bullae  form  surrounded  by  a  zone  of  congestion. 

Its  course  is  essentially  chronic,  and  while  the  older  lesions 
are  passing  away  new  ones  are  forming,  so  that  the  different 
stages  are  often  all  present  at  the  same  time  and  make 
up  a  truly  variegated  picture.  It  affects  mainly  the  trunk 
and  neck,  then  the  head,  face,  and  limbs.  An  analogous 
condition  has  also  been  observed  in  the  mouth  and  pharynx. 
Urticaria  factitia  is  common.  Itching  may  or  may  not  be 
present.  After  an  indefinite  and  variable  length  of  time 
new  lesions  are  no  longer  evolved,  those  already  formed 
disappear,  and  about  the  time  of  puberty  or  sooner  the 
trouble  has  run  its  course,  though  in  a  case  reported 
by  Levinski  tubercles  were  still  appearing  at  the  age  of 
eighteen. 

Most  authors  agree  that  the  disease  should  be  classified 
among  the  neuroses  of  the  skin,  or,  as  Hallopeau  expresses 
it,  among  the  trophic  neuroses.  The  characteristic  histo- 
logical  expression  of  the  disease  is  the  presence  in  great 
abundance  of  "mastzellen."  The  coloration  of  the  lesions 
is  due  to  the  presence  in  the  deeper  layers  of  the  epidermis 
of  pigment  granules. 

The  treatment  is  unsatisfactory,  but  relief  may  be  given 
to  a  certain  extent  by  the  remedies  employed  in  ordinary 
urticaria.  In  one  of  Crocker's  cases  the  development  of 
new  lesions  was  inhibited  by  the  administration  of  arsenic. 
Torok  and  Schein  report  a  cure  by  producing  an  acute 
or-ray  dermatitis. 


ACUTE  CIRCUMSCRIBED  EDEMA. 

Description. — The  disease  usually  comes  on  without  warn- 
ing in  the  shape  of  circumscribed  edematous  patches, 
varying  in  size  from  a  hickory  nut  to  an  orange,  of  a 


LICHEN  PLANUS  165 

light  or  dark  red  color,  and  disappears  as  rapidly  as  it 
came.  There  is  little  or  no  itching,  but  probably  some 
burning  and  a  sense  of  tension.  The  lips,  cheeks,  eye- 
lids, the  limbs,  and  the  mucous  membranes  of  the  mouth, 
pharynx,  and  larynx  may  be  attacked.  Many  different 
localities  may  be  affected  simultaneously,  or  one  only; 
vomiting  and  diarrhea  may  accompany  an  attack,  and 
Joseph  has  seen  paroxysmal  hemoglobin uria  associated 
with  it.  Recurrence  is  the  rule,  and  in  some  instances  the 
disorder  is  clearly  hereditary.  It  is  certainly  closely 
allied  to  the  giant  urticaria  described  by  Milton.  When  the 
disease  attacks  the  larynx  it  may  cause  death  by  suffoca- 
tion unless  promptly  relieved. 

Treatment. — The  treatment  is  essentially  that  of  urticaria 
(q.  v.}.  Ichthyol  in  5-gr.  doses,  three  times  a  day,  is  recom- 
mended by  Forster. 


LICHEN  PLANUS. 

Description. — Wilson  says  of  lichen  planus  that  it  is  a 
very  remarkable  form  of  eruption,  consisting  of  papules 
that  are  broad  at  the  base,  flat  and  seemingly  glazed  on  the 
summit,  slightly  umbilicated,  of  a  dull,  purplish-red  color 
at  first,  in  certain  situations  discrete  and  isolated,  in 
others  united  by  a  hyperemic  and  infiltrated  base  into 
patches  of  variable  extent.  Examined  somewhat  more  in 
detail,  and  in  the  light  of  further  study,  we  are  enabled  to 
determine  the  following  features : 

The  eruption  is  usually  symmetrically  disposed.  It 
nmy  appear  upon  any  part  of  the  body,  but  the  sites  of 
predilection  are  the  flexor  sides  of  the  forearms,  about  the 
wrists  particularly,  the  flanks,  around  the  waist,  lower 
part  of  the  abdomen,  around  the  knees  and  on  the  calves, 
less  frequently  on  the  hands  and  feet,  and  also  on  the 
mucous  membranes.  We  have  twice  seen  the  disease  on 
the  face. 


166  INFLAMMATIONS 

The  lesions  consist,  in  the  beginning,  of  round,  red  pap- 
ules, that  finally  become  more  or  less  angular  in  outline, 
varying  in  size  from  a  pin's  head  to  a  split  pea,  which 
project  abruptly  from  the  surface  of  the  skin  to  the 
height  of  about  a  line.  The  surface  of  the  papules  is 
smooth  and  shining,  quite  often  depressed  in  the  centre, 
and  sometimes  in  the  larger  papules  may  be  seen  white, 
milium-like  spots,  that  can  be  dug  out,  and  consist  of 
epithelium. 

After  reaching  their  full  development,  the  papules  do 
not  increase  by  peripheral  extension,  as  in  psoriasis,  for 
example,  but  they  may  go  on  multiplying  in  number. 
According  to  Robinson  the  surfaces  of  the  small,  isolated 
papules  are  devoid  of  scales,  but  in  older  and  larger  lesions 
a  thin,  transparent  layer  of  horny  cuticle  is  present. 

Wickham  states  that  on  the  papules,  when  one  is  accus- 
tomed to  observe  them,  may  be  seen  certain  whitish  points 
and  strife,  which  are  quite  characteristic,  and  are  similar 
in  appearance  to  the  whitish  lines  found  on  the  mucous 
membranes,  especially  the  cheeks,  when  those  parts  are 
affected  in  this  disease. 

The  papules  may  remain  isolated  throughout  their 
course,  or  they  may  be  disposed  in  groups,  lines  or  bands, 
or  have  a  ring-like  arrangement.  By  increase  in  the 
number  of  lesions,  and  their  close  aggregation,  variously 
sized,  sharply  limited,  elevated  patches  appear,  which  are 
covered  with  scales  and  closely  resemble  psoriasis.  At 
times  large  surfaces  may  be  thus  involved.  The  term 
lichen  verrucosus  is  applied  to  chronic  infiltrated  plaques 
whose  surfaces  may  be  plush-like,  or  else  horny  and  scaly 
(Jamieson).  These  patches  may  be  of  various  sizes,  and 
are  prone  to  involve  the  lower  limbs.  Vesicles  and  blebs 
have  been  noted  as  rare  complications.  A  number  of 
variations  from  the  classical  form  of  the  disease  have  been 
recorded. 

It  is  characteristic  of  lichen  planus  that  the  older  lesions 
leave  behind  them  marked  pigmentation  and  even  atrophic 
spots.  Itching  is  present  in  varying  degrees — sometimes 


LICHEN  PL  ANUS  167 

slight  or  again  very  intense.  The  hair  and  nails  are  never 
implicated.  The  majority  of  patients  with  lichen  planus 
that  have  come  under  our  observation  have  been  in  good, 
sometimes  robust  health,  or  else  have  exhibited  only  such 
systemic  disturbances  as  may  be  found  preceding  or  accom- 
panying any  other  affection  of  the  skin. 

T.  C.  Fox,  Crocker,  and  others  have  described  a  form 
of  lichen  planus  occurring  in  children.  The  papules  are 
acuminate  at  first,  but  later  become  flattened;  they  show 
a  tendency  to  grouping,  and  are  accompanied  by  much 
itching.  They  come  out  suddenly,  and  it  is  said  may  be 
made  to  disappear  quickly  by  soothing  applications. 

The  disease,  we  believe,  is  met  with  more  frequency  in 
females,  certainly  in  our  own  experience.  It  is  most  apt  to 
occur  in  adult  life,  although  not  unknown  in  childhood. 

The  essential  etiology  is  obscure.  Very  often  no  apparent 
exciting  cause  can  be  determined ;  at  other  times  a  probable 
causal  connection  may  be  established  for  various  forms  of 
nervous  exhaustion,  digestive  and  uterine  derangements, 
rheumatism,  etc. ;  in  fact,  just  such  disorders  of  the  health 
as  we  are  in  the  habit  of  connecting  with  eczema  and 
the  like  cutaneous  affections. 

Diagnosis. — The  diagnosis  of  lichen  planus  is  usually 
easy.  The  large,  angular  lesions  depressed  in  the  centre, 
their  shining  aspect,  purplish  color,  typical  situations,  and 
usual  symmetry  concur  in  presenting  a  clinical  picture 
that  is  readily  recognized.  Psoriasis,  syphilis,  and  papular 
eczema  should  not  be  confused  with  this  affection. 

Prognosis. — The  prognosis  is  generally  good,  as  regards 
recovery,  but  the  length  of  time  required  to  effect  a 
cure  cannot  be  foretold  with  any  exactness.  Relapses  are 
not  uncommon.  Cases  that  have  long  resisted  treatment 
will  occasionally  make  a  rapid,  spontaneous  recovery. 

Treatment. — As  regards  the  internal  treatment  of  lichen 
planus,  complications  should  be  removed  if  possible, 
and  any  appreciable  defect  of  the  general  health  should 
receive  the  proper  attention.  The  majority  of  patients, 
in  our  experience,  have  shown  -evidence  of  neuro- 


168  INFLAMMATIONS 

pathy.  This  seems  especially  true  of  those  cases  in  which 
the  lesions  are  markedly  pruritic.  Treatment  should 
accordingly  be  directed  to  this  condition.  We  have  often 
found  the  bromides  of  use.  Whitfield  uses  opium  in  cases 
with  much  itching  and  nervous  excitement,  not  only  for  its 
effect  on  the  nervous  condition,  but  on  the  eruption  as 
well.  A  few  days'  rest  in  bed  will  occasionally  have  a 
magical  effect;  when  the  disorder  is  associated  with  over- 
work, worry,  or  insomnia,  a  removal  of  these  conditions 
will  sometimes  effect  a  cure.  We  have  seen  a  vacation 
work  a  cure. 

In  acute  cases  the  alkaline  diuretics  may  be  given  with 
advantage. 

T^ — Potassii  acetatis 5ss-5j 

Tr.  nucis  vpmicae 3|j 

Infus.  gentianse q.  s.  ad     3iv — M. 

S. — Teaspoonful  in  a  wineglass  of  water  after  meals. 

Quinine  in  fairly  large  doses,  8  to  12  gr.  a  day,  and  salicin 
in  15-gr.  doses  thrice  daily  are  also  valuable  in  the  general- 
ized hyperemic  cases.  In  similar  conditions  we  have  seen 
benefit  from  the  chloride  of  calcium,  20  to  40  gr.,  well 
diluted,  three  times  a  day.  Brooke  gives  15  minims  of  the 
wine  of  antimony,  three  times  a  day,  and  has  found  it  very 
helpful.  When  a  neurasthenic  condition  exists  we  pre- 
scribe, for  the  rich,  change  of  air  and  occupation,  and,  for 
the  poor,  extract  of  cannabis  (Allen's)  in  \  gr.  doses. 
When  there  is  hysteria,  this  drug  is  at  times  productive  of 
harm. 

In  subacute  and  chronic  cases  of  lichen  planus,  more 
especially  those  in  which  the  disorder  involves  extensive 
portions  of  the  body,  the  remedies  of  greatest  value  are 
arsenic  and  mercury.  Arsenic  is  usually  prescribed  in 
the  form  of  Fowler's  solution,  but  any  of  the  other  prepara- 
tions of  the  drug  may  be  employed,  or  it  may  be  given 
subcutaneously. 

If  Fowler's  solution  is  selected,  it  is  best  to  begin 
with  2  drops,  largely  diluted,  immediately  after  meals,  and 
then  gradually  to  run  it  up  to  8  or  10  drops,  unless  the 


LICHEN  PLANUS  169 

point  of  tolerance  is  reached  with  a  smaller  dose,  which 
often  happens.  If  the  disease  should  be  made  worse  by 
the  arsenic,  or  no  effect  on  the  disease  be  noted,  its  use 
should  be  abandoned,  and  some  preparation  of  mercury 
given  in  its  stead.  Mercury  either  in  the  form  of  the 
bichloride  or  the  biniodide,  our  own  preference  being  for 
the  latter,  may  be  prescribed  in  the  dose  of  -^  to  ^  gr. 
The  biniodide  may  be  given  in  pill  form  or  in  the  fol- 
lowing mixture: 

1^ — Hydrargyri  biniodidi gr.  j-ij 

Potass,  iodidi 5ss 

Ess.  pepsini 5iij 

Aquae q.  s.  ad     5iv — M. 

S. — Teaspoonf ul  in  one-quarter  glass  of  water  after  meals. 

It  is  always  well  to  continue  the  internal  treatment  for 
a  number  of  weeks  after  the  disappearance  of  the  eruption. 

Locally,  in  acute  cases,  when  considerable  surface  is 
involved,  alkaline  baths  and  soothing  lotions  are  demanded. 
The  calamine  and  zinc  lotion,  to  which  has  been  added  a 
small  quantity  of  tar,  is  admirable  for  the  itching : 

1$ — Liq.  carbonis  detergentis 5j 

Lotionis  zinci  et  calaminee 3vj — M. 

S. — Mop  on  frequently. 

Instead  of  the  tar,  2  drachms  of  menthol,  first  dissolved 
in  a  little  alcohol,  may  be  added  to  the  zinc  and  calamine 
lotion;  or  the  menthol  may  be  ordered  in  the  form  of  a 
salve. 

In  chronic  cases  the  treatment  should  be  more  stimu- 
lating. Wilson  recommended  a  bichloride  of  mercury 
lotion  of  the  strength  of  2  gr.  to  1  oz.  Vleminckx's  solu- 
tion may  also  be  employed,  which  latter,  however,  should 
be  diluted  at  first.  Unna  extols  the  following,  with  which 
the  patient  should  be  rubbed  twice  a  day,  being  kept  in  bed 
in  the  mean  time : 

]$ — Hydrargyri  bichloridi gr.  ij-v 

Acidi  carbolici gr.  x-xx 

Ung.  zinci  oxidi 5j — M. 


170  INFLAMMATIONS 

The  following  formula  may  also  be  used  to  advantage  in 
some  instances: 

1$ — Liq.  carbonis  detergentis 
Zinci  sulphatis, 
Potassae  sulphuratae      .      .     -.      .      . 

Glycerin! 5ij 

Aquae  rosse q.  s.  ad     3iv — M. 

We  have  used  a  pigment  of  chrysarobin  and  salicylic 
acid  with  much  satisfaction  in  localized  patches. 

1^ — Chrysarobini gr.  xl 

Acidi  salicylici gr.  xl 

Traumaticini 3j — M. 

S.— Paint  on  with  camel's-hair  pencil. 

The  tincture  of  green  soap  with  tar  is  also  valuable.  We 
generally  prefer  the  following  formula  of  Piffard's,  some- 
what modified: 

1$ — Saponis  olivse  praep 5iv 

Olei  rusci, 

Glycerini aa  5j 

Olei  rosmarini 3jss 

Alcoholis q.  s.  ad  Sviij — M. 

S. — Rub  in  with  a  piece  of  flannel. 

Jacquet  and  Brocq  warmly  advocate  hot  sedative 
douches.  The  water  of  a  temperature  varying  between 
34°  and  38°  C.,  according  to  personal  susceptibility,  is 
poured  upon  the  body  from  a  watering  pot  with  a  wide 
nozzle,  care  being  taken  that  it  should  not  be  projected  too 
energetically.  The  duration  of  the  douche  is  two  to  five 
minutes.  Sometimes  this  process  may  be  concluded  with 
a  cold  jet  of  water  lasting  a  few  moments.  We  have,  on  the 
other  hand,  had  good  results  from  cold  water  alone. 

The  x-ray,  used  much  in  the  same  way  as  for  psoriasis 
(p.  118),  is  invaluable  in  the  treatment  of  infiltrated  and 
localized  forms  of  the  disease;  indeed  this  agent  has 
largely  superseded  the  strong  medicinal  applications  just 
mentioned,  and  the  cautery  applications  of  Lassar  and 
others.  In  generalized  lichen  planus  we  have  not  obtained 
such  good  results  from  the  x-ray.  We  have  not  been  much 


LICHEN  PILARIS  171 

impressed  with  the  value  of  the  high-frequency  current, 
although  both  it  and  static  electricity  have  been  recom- 
mended in  close  and  dense  patches.  In  such  cases  Stel- 
wagon  uses  labile  applications  of  a  weak  galvanic  current. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Ol.  rusci  (vel  cadini) 5j 

Ung.  hydrargyri 5ij 

Ung.  simplicis 5j — M. 

S. — Local  use.  Taylor. 

1$ — Liq.  plumbi  subacetat rr^xv 

Liq.  picis  carb.,  B.  P n\xv 

Ung.  zinci 5j — M. 

S. — As  a  soothing  application.  Brooke. 

1$ — Liq.  picis  carb.,  B.  P 5  j 

Hydrarg.  perchloridi gr.  ij 

Spts.  vini  rectific 3iv 

Aquam  destillat q.  s.  ad  5xvj 

S.— Local  use.  Whitfield. 


LICHEN  PILARIS.1 

Description. — Crocker  describes,  under  the  name  of  lichen 
pilaris,  or  lichen  spinulosus  (Devergie)  an  inflammatory 
disease  of  the  hair  follicles  in  which  a  spiny  epidermic  peg 
occupies  the  centre  of  the  papule.  It  resembles  keratosis 
pilaris  somewhat,  especially  when  the  inflammation  has 
subsided,  but,  according  to  Crocker,  although  the  last- 
mentioned  disease  has  an  epidermic  plug,  it  is  not  spiny 
like  that  of  lichen  pilaris,  and  there  is  no  objective  redness. 
Besides,  lichen  pilaris  is  not  a  diffuse  eruption,  but  occurs 
in  acute  or  subacute  crops,  arranged  in  patches  on  the 
back  of  the  neck,  buttocks,  trochanteric  regions,  abdomen, 
back  of  thighs,  popliteal  spaces,  and  extensor  surfaces  of 
the  arms. 

1  See  Adamson,  British  Journal  of  Dermatology,  February  and 
March,  1905,  for  a  full  account  of  this  affection. 


172  INFLAMMATIONS 

Treatment. — Alkaline  baths,  and  frictions  with  the  hand 
while  in  the  bath,  are  advised  as  preliminary  measures, 
followed  by  a  liniment  of  soft  soap  and  tar.  Internally, 
tonic  treatment  is  required. 


PITYRIASIS  RUBRA  PILARIS.1 

Description. — There  would  seem  to  be  no  question  that 
the  greater  number  of  cases  described  as  lichen  ruber 
acuminatus  are  really  examples  of  the  disorder  now  defi- 
nitely recognized  as  pityriasis  rubra  pilaris.  The  beginning 
of  the  disorder  is  by  no  means  uniform.  In  rare  instances 
there  is  an  acute  onset  in  which  there  is  a  more  or  less 
generalized  scarlatiniform  redness  of  the  skin  (erythro- 
dermia),  with  special  localization  on  the  hands  and  feet, 
and  considerable  systemic  reaction;  these  symptoms  soon 
abate,  however,  and  the  affection  runs  its  usual  indolent 
course. 

In  the  majority  of  cases  the  development  is  gradual. 
Sometimes  it  may  begin  with  the  appearance  of  character- 
istic papules  scattered  over  the  trunk  or  upper  limbs, 
especially  upon  the  postero-external  surfaces  of  the  fore- 
arms and  on  the  dorsal  surfaces  of  the  phalanges ;  or  again 
as  a  dry,  scaly  eruption  upon  the  palms  and  soles.  It  is 
pointed  out  that  we  should  regard  with  suspicion  marked 
and  chronic  desquamation  of  the  bed  of  the  nail,  and  the 
presence  of  seborrheic  scales  upon  the  scalp,  redness  of 
the  skin  of  the  face,  and  a  pityriasic  desquamation  of  the 
eyebrows  and  beard.  The  characteristic  expression  of  the 
disease  is  in  the  form  of  acuminate  or  conical,  more  rarely 
round  or  umbilicated  papules.  These  lesions  are  pierced 
by  atrophied  hairs,  which  are  ensheathed  in  horny  and 
sebaceous  layers  that  dip  down  into  the  follicle.  They  are 

1  Those  interested  in  the  "lichen  question"  can  obtain  full  infor- 
mation in  the  standard  text-books.  The  description  of  the  disease 
here  given  is  largely  taken  from  Brocq's  article  in  the  Twentieth 
Century  Practice  Of  Medicine,  1897. 


PITYRIASIS  RUBRA  PILARIS  173 

dry,  rough  to  the  touch,  making  the  integument  to  feel  like 
the  skin  of  a  plucked  fowl,  more  or  less  red,  but  at  times 
brownish  or  grayish  white.  The  papules  are  isolated  in 
the  beginning,  but  gradually  increase  in  numbers  and 
eventually  run  together.  The  papules  are  found  in  those 
regions  where  the  hair  is  most  abundant,  that  is,  on  the 
first  and  second  phalanges  of  the  fingers,  on  the  outer 
aspect  of  the  forearms,  the  outside  of  the  thighs,  the  legs, 
the  buttocks,  but  also  in  the  neighborhood  of  the  elbows 
and  knees,  about  the  waist  and  the  inferior  part  of  the 
abdomen. 

After  the  coalescence  of  the  papules  has  occurred  from 
increase  in  number  of  the  lesions,  the  individual  papules 
are  lost  in  yellowish  or  brownish-red  patches  covered  with 
micaceous  scales.  The  skin  becomes  much  thickened,  its 
natural  folds  are  exaggerated,  and  it  assumes  a  permanent 
yellowish  color.  At  the  borders  of  the  patches  it  is  gener- 
ally possible  to  discover  the  typical  conical  papule  char- 
acteristic of  the  disease,  but  this  is  not  always  easy, 
and  at  times  the  implication  of  the  integument  is  general. 

When  the  disease  attacks  the  face,  as  it  does  in  most 
instances,  the  skin  presents  different  aspects;  at  times  it  is 
of  a  dusky  red,  with  much  contraction  and  subsequent 
ectropion,  or  it  is  covered  with  greasy  crusts,  or  presents  a 
fine  desquamation.  The  scalp  exhibits  usually  a  furfur- 
aceous  desquamation,  but  according  to  Brocq  there  are  no 
cones  surrounding  the  hair,  ana  the  skin  is  not  appreci- 
ably red;  more  rarely  there  is  a  marked  seborrhea  of 
this  region. 

The  skin  of  the  palms  and  soles  is  sometimes  greatly 
thickened,  or  these  surfaces  exhibit  reddened  patches,  are 
dry  and  itchy,  with  slight  desquamation  and  an  exaggera- 
tion of  the  usual  lines  and  furrows.  The  nails  present 
diverse  appearances,  sometimes  being  marked  with  trans- 
verse furrows  or  else  with  longitudinal  elevations  and 
depressions;  or  again  they  will  be  thickened.  Pain  may  be 
present  to  a  considerable  degree.  Subjective  symptoms 
are  said  to  be  absent  in  most  cases,  but  at  times  there  may 


1 74  INFLAMMA  TIONS 

be  marked  pruritus.  It  is  also  claimed  by  European 
authorities  that  the  general  health  of  the  patient  is  unim- 
paired, but  we  have  occasionally  seen  marked  impairment 
of  the  general  health,  and  much  local  distress. 

The  etiology  of  this  disease  is  obscure.  It  is  said  to  be 
more  frequent  in  men  than  in  women,  and  according  to 
Besnier,  while  it  may  begin  at  any  time  of  life,  it  is  most 
apt  to  appear  for  the  first  time  in  infancy  or  youth.  Jacquet 
has  found  that  the  cone  surrounding  the  hair  is  due  to 
an  exaggerated  cornification  of  the  epithelial  wall  of  the 
infundibulum  of  the  follicle. 

Prognosis. — The  prognosis  is  usually  favorable,  but  re- 
lapses are  common. 

Treatment. — The  results  of  internal  treatment  are  not 
especially  encouraging.  Pilocarpine  by  the  mouth  or  hypo- 
dermically  will  relieve,  temporarily,  the  excessive  dryness 
of  the  skin.  Brocq  recommends  arseniate  of  sodium  in 
increasing  doses.  Hyde  and  Montgomery  have  observed 
marked  amelioration  of  the  symptoms  from  the  combined 
use  of  arsenious  acid,  ^  gr.,  and  protiodide  of  mercury, 
£  gr.,  given  three  times  a  day,  but  these  drugs  have 
been  employed  in  connection  with  local  applications. 
Thyroid  extract  has  been  given  with  some  asserted  advan- 
tage. Locally,  an  antiphlogistic  treatment  (Leredde) 
should  be  employed  when  inflammatory  conditions  are 
present,  that  is,  soothing  pastes  and  ointments. 

The  following  ointment  gives  much  comfort: 

T$ — Acidi  salicylici gr.  x 

Ol.  amygdalae  dulcis oij 

Lanolini 3vj — M. 

A  salve  that  is  valuable  in  ichthyosis  is  also  useful  in 
this  disease,  namely : 

1^ — Adipis  benzoati 5j 

Glycerin! n\xl 

Vaselini §ss — M. 

Weak  tar  ointments  are  also  recommended,  but  we  have 
found  tar  objectionable  for  various  reasons.  In  irritable 


DERMATITIS  GANGR&NOSA  175 

states  of  the  skin  simple  warm  baths,  to  which  has  been 
added  bran  or  starch,  or  vapor  baths,  prove  acceptable. 
Usually,  however,  a  bath  rendered  alkaline  by  the  addition 
of  8  or  10  oz.  of  carbonate  of  sodium  gives  the  best  results, 
especially  if  followed  by  the  inunction  of  one  of  the  salves 
mentioned  above,  or,  indeed,  of  simple  vaselin.  In  more 
chronic  states,  pyrogallic  acid,  chrysarobin,  and  such  reme- 
dies may  be  prescribed  as  in  psoriasis.  Strong  salicylic 
plasters  may  be  employed  for  the  thickened  patches  on  the 
palms  and  soles.  The  scalp  may  be  treated  as  in  seborrhea 
by  shampooing  with  green-soap  tincture  and  the  application 
of  a  weak  salicylic  acid  salve.  Pusey  obtained  considerable 
persistent  improvement  in  one  case  by  the  o;-ray  carried  to 
the  first  degree  of  reaction. 


DERMATITIS  GANGR-ffiNOSA. 

Description. — Gangrene  of  the  skin  may  result  from  a 
great  variety  of  causes,  local  and  constitutional;  for 
example,  it  may  follow  upon  the  prolonged  or  excessive 
action  of  heat  or  cold,  from  the  application  of  chemical 
agents,  from  the  internal  use  of  ergot,  from  shock,  and  in 
symptomatic  connection  with  various  cerebral  and  spinal 
disorders;  also,  from  various  changes  within  the  vessels, 
alterations  in  the  vessel  wall,  and  from  pressure.  From 
the  clinical  standpoint  the  following  types  may  be  men- 
tioned : 

Multiple  Gangrene  of  the  Skin. — It  was  formerly  held 
that  this  type  of  the  disease  occurred  mainly  in  young 
women  and  was  artificially  produced,  and  while  this  is 
probably  correct  for  most  instances,  it  has  been  shown 
that  this  is  not  always  the  case.1  The  affection  has  been 
observed  in  men  and  also  in  children.  Lessened  tissue 
resistance  and  local  infection  are  probably  the  etiological 
factors  involved. 

1  See  especially  Van  Harlingen,  American  Journal  Medical  Sciences, 
July,  1897. 


176  INFLAMMATIONS 

Diabetic  Gangrene. — The  gangrene  of  the  skin  that 
sometimes  occurs  in  connection  with  diabetes  may  arise 
spontaneously  or  follow  upon  some  traumatism,  or  appear 
in  connection  with  some  one  of  the  cutaneous  disorders 
that  accompany  the  disease.  The  extremities,  particularly 
the  lower,  are  especially  liable  to  attack,  the  gangrene 
being  unilateral.  The  genitalia  may  also  be  involved. 

Symmetrical  Gangrene  (Raynaud's  disease). — This 
affection  consists  of  three  morbid  conditions,  probably  due 
to  one  and  the  same  cause,  viz.,  vasomotor  spasm  of  the 
arterioles,  usually  of  the  extremities,  and  a  consequent 
retardation  of  the  circulation  in  the  parts  attacked.  Ray- 
naud  divided  the  disease  into  three  stages  as  follows: 
Local  syncope,  local  asphyxia,  and  local  gangrene.  The 
process  does  not  necessarily  pass  from  one  stage  into 
another;  it  may  stop  short  of  the  extreme  stage  of  the  dis- 
ease, or  exhibit  other  variations  in  its  course.  Neither  is 
it  always  symmetrical,  and  other  parts  than  the  extremities 
may  be  attacked,  such  as  the  nose,  ears,  etc.  Raynaud's 
disease  is  more  common  in  women  than  in  men,  and  it  is 
frequent  between  the  ages  of  fifteen  and  thirty,  although  it 
has  been  observed  in  young  children. 

Dermatitis  Gangraenosa  Infantum. — Gangrene  of  the 
skin  in  young  children  is  of  not  infrequent  occurrence  after 
varicella  and  other  cutaneous  affections.  Tuberculosis 
and  syphilis  are  also  said  to  be  predisposing  influences. 
It  is  most  common  under  the  age  of  three  years,  and  con- 
sists of  superficial  or  deep  ulcerations  covered  by  a  slough 
situated  on  the  site  of  the  original  lesion,  or  it  may  occur 
independently.  In  some  cases  the  patches  of  gangrene  are 
widely  scattered  and  numerous,  accompanied  by  high 
fever  and  leading  to  a  rapidly  fatal  ending;  or  there  may 
appear  a  series  of  small  pustules,  each  of  which  sloughs 
and  leaves  a  small  scar  with  an  indefinite  prolongation  of 
the  disease  by  successive  crops.  Microbic  infection  is 
highly  probable. 

Prognosis. — In  multiple  gangrene  of  the  skin,  the  prog- 
nosis is  usually  good  in  the  long  run ;  in  diabetic  gangrene 


DERMATITIS  GANGR&NOSA  177 

the  outlook,  except  in  some  cases  of  the  spontaneous  form, 
is  unfavorable;  in  Raynaud's  disease  there  may  be  a  single 
attack  without  relapse,  but  recurrence  is  the  rule  and  the 
prognosis  is  unfavorable;  dermatitis gangrsenosa  infantum, 
with  numerous  lesions  and  marked  systemic  disturbance, 
is  a  grave  disorder,  but  the  prognosis  is  good  in  slight 
cases,  and  under  judicious  treatment  those  of  an  apparently 
serious  nature  get  well. 

Treatment. — The  treatment  of  the  various  forms  of  gan- 
grene of  the  skin  consists  in  ascertaining  and  removing 
the  underlying  cause  of  the  disturbance,  and  the  main- 
tenance of  the  general  health  by  appropriate  tonics  and 
proper  food. 

In  so-called  multiple  or  spontaneous  gangrene  the  general 
principle  of  seeking  the  cause  of  the  complaint  should  be 
followed.  At  the  same  time  it  should  be  remembered 
that  Audry  thinks  that  some  of  the  cases  are  due  to  the 
administration  of  the  iodides  or  bromides.  These  drugs 
should  therefore  be  employed  with  discrimination. 

In  diabetic  gangrene  the  causative  disease  must  receive 
proper  attention,  dietetically  and  medicinally.  Nitro- 
glycerin  may  be  of  use.  Opium  is  generally  indicated. 

The  general  treatment  of  Raynaud's  disease  demands 
close  attention  to  the  health  of  the  patient,  and  it  is  said 
that  much  can  be  accomplished  by  preventing  exposure 
to  cold,  and  by  securing  a  good  circulation  by  bathing  and 
judiciously  selected  clothing.  Quinine  has  appeared  of 
benefit  in  some  cases.  Nitroglycerin  and  erythrol  tetra- 
nitrate  have  been  recommended  in  the  asphyxial  stage. 
We  have  tried  the  former  without  any  very  satisfactory 
results.  Raynaud  advised  the  use  of  a  descending  gal- 
vanic current.  If  applied  to  the  spine  the  positive  pole  is 
placed  in  the  region  of  the  neck  at  the  fifth  cervical  verte- 
bra, and  the  negative  at  the  sacrum  and  lower  lumbar 
region;  or  the  negative  pole  may  be  placed  directly  over 
the  diseased  parts.  A  strong  current  is  used  daily  for  five 
or  ten  minutes.  Barlow  directs  that  the  affected  limb 
should  be  placed  in  a  basin  of  warm  water  and  salt,  together 
12 


178  INFLAMMATIONS 

with  one  pole  of  the  battery,  while  the  other  pole  should 
be  placed  on  the  member  at  its  upper  portion.  A  current 
should  be  used  as  strong  as  the  patient  can  tolerate.  T.  K. 
Monroe  advises  the  same  procedure,  except  that  he  uses  a 
low  voltage  and  amperage  for  one-half  hour  twice  daily. 
Shampooing  is  also  a  valuable  adjunct.  Faradism  has 
its  advocates. 

In  the  gangrene  of  infancy  Crocker  thinks  well  of  5-gr. 
doses  of  sulphocarbolate  of  sodium,  and  quotes  Coutts  as 
advising  opium.  In  our  opinion  opium  is  an  excellent 
remedy  in  gangrene  from  any  cause,  both  for  its  direct 
effect  and  indirectly  as  a  means  of  relieving  pain  and 
quieting  restlessness. 

The  local  treatment  of  the  various  forms  of  gangrene  of 
the  skin  is  mainly  surgical.  In  gangrene  of  the  skin  of 
children,  the  sloughs  should  be  removed  by  antiseptic 
lotions  of  carbolic  acid,  and  upon  separation  the  ulcerated 
surfaces  may  be  treated  by  aristol  or  xeroform,  either  dry 
or  in  vaselin.  Crocker  stops  the  extension  of  the  gangrene 
and  the  surrounding  infiltration  by  subcutaneous  injections 
of  carbolic  acid  1  in  40,  near  the  sloughing  ulcers;  if  the 
gangrenous  patch  is  large,  three  or  four  injections  around 
it,  3  or  4  minims  to  each  spot,  may  be  necessary. 


DERMATITIS  MEDIC AMENTOSA. 

Description. — It  is  of  great  importance  for  the  physician 
to  remember  that  eruptions  of  the  skin  follow  upon  the 
taking  of  many  drugs;  in  fact,  under  certain  circumstances 
any  drug  may  give  rise  to  cutaneous  symptoms,  although 
these  effects  are  more  prone  to  occur  after  the  administra- 
tion of  certain  remedies  than  after  others;  thus,  the  salts 
of  iodine  or  bromine,  if  taken  largely  and  for  long  periods, 
will  almost  invariably  produce  skin  eruptions,  while  it  is 
an  exceptional  circumstance  for  quinine  to  be  followed 
by  any  similar  disturbance.  According  to  Van  Harlingen , 
these  medicinal  eruptions  occur  in  fairly  well-defined 


DERMATITIS  MEDICAMENTOSA  179 

groups,  and  are  more  or  less  alike  in  their  features.  Ery- 
thematous,  scarlatiniform,  and  urticarial  rashes  are  the 
usual  types  presented;  less  frequently  they  are  pustular, 
bullous,  nodular,  and  purpuric.  Ulcerative  and  gangrenous 
lesions  are  observed  among  the  untoward  effects  of  some 
drugs,  and  it  is  well  known  that  herpes  zoster,  keratoses, 
and  pigmentation  of  the  skin  are  by  no  means  infrequent 
consequences  of  arsenical  medication. 

Treatment. — The  treatment  of  the  various  forms  of  drug 
eruption  consists  naturally  in  suspending  the  use  of  the 
offending  drug;  but  sometimes  it  is  quite  essential  to  keep 
on  with  the  latter  notwithstanding  its  evil  effects.  A 
number  of  remedies  have  been  suggested  as  capable  of 
modifying  the  action  of  the  bromide  compounds,  such  as 
arsenic,  sulphide  of  calcium,  belladonna,  and  the  aromatic 
spirit  of  ammonia.  The  simultaneous  local  use  of  a  sul- 
phur lotion  is  also  valuable  in  preventing  bromic  acne. 

Morrow  gives  Yinrgr-  atropine  to  counteract  the  effect  of 
the  iodides  on  the  nasal  and  conjunctival  mucous  mem- 
branes, and  we  are  in  the  habit  of  prescribing  5  minims 
or  more  of  the  tincture  of  nux  vomica  with  iodide  mixtures. 
The  drug  may  also  be  taken  in  milk,  vichy,  junket,  essence 
of  pepsin,  etc. 

Unna  advises  the  use  of  dilute  hydrochloric  acid  and 
other  mineral  acids  to  prevent  the  poisonous  effects  of 
pyrogallol  and  chrysarobin,  thus  diminishing  the  alka- 
linity of  the  blood.  Netter  states  that  the  administration 
of  chloride  of  calcium  prevents  serum  rashes.  On  the  day 
of  injection  he  gives  1  gram,  and  this  dose  is  repeated 
for  the  two  following  days. 

The  local  treatment  differs  in  no  way  from  the  treatment 
that  would  ordinarily  be  employed  for  similar  rashes  due 
to  other  causes. 

The  sometimes  very  formidable  carbuncular  (anthra- 
coid)  lesions  due  to  iodine  or  bromine  preparations  usually 
do  well  under  soothing  and  antiseptic  ointments,  e.  g., 
xeroform,  10  per  cent.,  to  unguentum  vaselini  plumbicum, 
1  oz.,  spread  on  patent  lint;  or  if  this  should  not  prove  suit- 


180  INFLAMMATIONS 

able,  a  bismuth  and  carbolic  acid  salve,  $  oz.  of  the  former, 
5  to  10  minims  of  the  latter,  to  1  oz.  of  vaselin. 

Gottheil  recommends  a  5  per  cent,  salicylic  acid  dusting 
powder,  or  paste,  as  useful  in  shrivelling  up  the  fleshy 
excrescences,  and,  in  obstinate  cases,  curettage  under  local 
anesthesia. 

DERMATITIS    FACTITIA. 

Description. — Feigned  eruptions  or  eruptions  that  have 
been  produced  artificially  by  hysterics  and  malingerers 
are  far  from  uncommon,  and  while  their  treatment  is  usually 
that  of  the  kind  of  disturbances  thus  set  up,  a  few  words 
on  the  general  subject  may  not  be  out  of  place.  The  fol- 
lowing points  should  be  remembered  in  establishing  a 
diagnosis.  In  the  first  place  we  should  ascertain,  if  possible, 
the  history  of  the  patient,  moral  and  physical,  and  note 
carefully  the  present  condition;  secondly,  we  should  dis- 
cover if  the  patient  has  had  any  previous  skin  diseases  and 
whether  he  had  been  or  was  at  the  time  making  use  locally 
or  internally  of  any  medicinal  preparations.  We  should 
make  a  mental  comparison  of  the  lesions  present  with 
other  known  eruptions  and  note  any  special  anomaly. 
The  shape  of  the  lesion  will  often  furnish  a  hint.  Finally, 
it  must  be  remembered  that  eruptions  produced  with 
intent  to  deceive  generally  occupy  accessible  situations,  and 
in  right-handed  people,  for  example,  are  apt  to  be  found 
on  the  left  side  of  the  body 

According  to  the  agent  employed,  the  lesions  produced 
will  occur  in  erythematous  or  excoriated  patches,  as,  for 
example,  from  the  application  of  mustard  or  rubbing;  or 
they  will  be  bullous  or  pustular,  or  present  superficial  or 
deep  ulceration,  or  such  disturbances  as  could  be  caused 
by  acids, croton  oil,  cantharides,  or  carbolic  acid;  or  they 
will  consist  of  scratch  marks  made  by  the  nails  or  some 
instrument;  or  burns  produced  by  the  application  of  a 
lighted  cigarette;  or,  finally,  of  some  discoloration  of  the 
skin  brought  about  by  the  use  of  blacklead,  silver  nitrate, 


DERMATITIS  V EN  EN  AT  A  181 

etc.,  or,  as  in  one  of  our  cases,  by  that  of  the  red  pigment 
used  in  china  painting,  to  simulate  hemorrhage. 

Very  often  an  ulceration,  for  example,  that  has  almost 
healed  under  suitable  treatment  will  suddenly  become 
worse  under  renewed  irritation,  secretly  inflicted,  and  to 
expose  the  trick  it  may  be  necessary  to  put  on  a  bandage 
in  such  a  way  that  its  disturbance  by  the  patient  will  be 
quickly  detected.  At  times  the  nature  of  the  substance 
that  is  supposed  to  be  at  the  root  of  the  difficulty  may  be 
discovered  by  chemical  means. 


DERMATITIS  TRAUMATICA. 

In  this  group  are  to  be  found  those  inflammatory  changes 
in  the  skin  resulting  from  traumatism,  such,  for  example, 
as  excoriations  and  abrasions  from  scratching,  from  the 
pressure  of  tight  or  ill-fitting  shoes,  awkwardly  applied 
bandages,  braces,  etc.  There  are  marked  pigmentation 
and  induration  of  the  skin,  when  the  source  of  irritation  is 
long  continued.  The  treatment  consists  in  the  removal  of 
the  cause,  and  the  application  of  remedies  of  a  soothing 
character. 

DERMATITIS  VENENATA.1 

.This  title  is  usually  accepted  as  meaning  all  forms  of 
inflammation  of  the  skin  produced  by  external  irritating 
agencies,  whether  from  the  animal,  vegetable,  or  mineral 
kingdoms.  The  number  of  substances  capable  of  exciting 
this  pathological  state  is  exceedingly  large,  and  those 
liable  to  such  attacks  are  to  be  found  in  all  the  relations  of 
life.  The  mineral  irritants  are  numerous,  as,  for  example, 
the  coloring  material  in  wearing  apparel,  the  various 
chemicals  employed  in  the  trades,  and  the  substances  that 
go  to  make  up  many  of  the  commercial  soaps. 

1  For  a  full  treatment  of  this  subject  see  White's  valuable  mono- 
graph on  Dermatitis  Venenata,  Boston,  1888. 


182  INFLAMMATIONS 

Vegetable  Substances. — White  has  shown  that  more  than 
sixty  plants  are  to  be  found  in  the  United  States  that  may 
give  rise  to  varying  degrees  of  dermatitis.  In  particular 
there  are  four  species  found  in  this  country  that  are  capable 
of  producing  active  inflammation  of  the  skin  of  individuals 
exposed  to  their  influence,  whether  from  actual  contact 
or  mere  proximity.  These  are  Rhus  toxicodendron,  Poison 
Ivy  or  Poison  Oak;  Rhus  venenata,  Poison  Sumach,  Poison 
Dogwood  or  Poison  Elder;  Rhus  diversiloba,  met  with  on 
the  Pacific  coast,  and  Rhus  pumila,  the  most  poisonous  of  all, 
a  procumbent  shrub  of  South  Carolina.  Pfaff  has  pointed 
out  the  error  of  Maisch's  conclusions  in  regard  to  toxi- 
codendric  acid,  and  has  shcrtvn  that  the  irritant  principle  is 
a  fixed  oil  called  by  him  toxicodendrol.  The  character  of 
the  dermatitis  from  rhus  poisoning  varies  in  intensity; 
sometimes  it  is  merely  an  erythema,  or  there  are  a  few 
scattered  papules,  or  else  there  supervenes  acute  swelling 
of  the  skin  with  the  formation  of  vesicles,  pustules,  and 
blebs.  There  are  marked  sensations  of  itching  and  burning. 
The  hands,  face,  and  genitals  are  usually  involved,  some- 
times the  entire  surface.  The  disease  may  last  from  one 
to  six  weeks.  The  poisonous  principle  may  be  conveyed 
in  an  early  stage  of  the  affection  from  one  part  of  the  body 
to  another,  or,  perhaps,  to  a  second  person;  but  according 
to  White,  after  the  poison  has  been  absorbed  or  removed  by 
washing  or  volatilization,  there  is  no  risk  of  contagion. 
The  effects  of  exposure  show  themselves  in  from  a  few 
hours  to  several — four  or  five — days. 

Susceptibility  to  rhus  poisoning  once  established  would 
appear  to  be  more  or  less  permanent. 

Treatment. — The  treatment  of  dermatitis  venenata  should 
be  conducted  on  general  principles,  taking  care,  of  course, 
to  rid  the  skin  of  the  source  of  irritation  as  soon  as  pos- 
sible. There  are  many  so-called  specifics  for  rhus  poison- 
ing, for  the  reason  that  the  dermatitis  varies  greatly  in 
degree,  and  the  affection  runs  a  tolerably  definite  course. 
Under  any  circumstances,  a  method  of  much  value  is  to 
wash  the  affected  parts  immediately  with  soap  and  hot 


DERMATITIS  YEN  EN  AT  A  183 

water.  This  is  to  be  done  freely  with  a  copious  lather,  and 
for  a  considerable  time.  Balch  follows  this  by  washing 
the  part  in  95  per  cent,  alcohol,  repeatedly  pouring  the 
latter  over  the  surface  to  dissolve  the  toxicodendrol.  As 
a  medicinal  application  we  have  found  hourly  mopping 
with  sulphate  of  zinc  lotion  of  the  strength  of  from  3j~3ss 
to  water  Oj  to  be  of  much  service.  Black  wash — calomel 
3 j,  lime-water  Oj — is  an  excellent  application,  used  as  a 
lotion  upon  linen,  for  one-half  hour  at  a  time.  This  should 
not  be  used  over  too  extensive  surfaces.  Preparations  of 
lead  are  especially  valuable,  being  antidotal  to  toxico- 
dendrol. With  an  unbroken  skin  we  often  use  1  part  of 
lead-water  to  3  parts  of  plain  water,  and  later  the  unguen- 
tum  vaselini  plumbicum.  A  remedy  of  universal  applica- 
tion is,  according  to  White,  made  as  follows : 

1$ — Zinci  oxidi 5iv 

Acidi  carbolic! 3j 

Liq.  calcis Oj — M. 

S. — Shake  and  mop  over  affected  surface  repeatedly,  day  and 
night. 

Klotz  has  found  ichthyol  of  much  value. 

Sometimes  in  limited,  very  itchy  patches,  where  the 
papular  element  predominates,  Pick's  linimentum  exsic- 
cans1  with  1  per  cent,  of  carbolic  acid  and  10  per  cent,  of 
zinc  oxide  gives  a  very  satisfactory  result.  It  must  be 
smeared  over  the  parts  very  thinly  and  gently.  It  is  readily 
removed  with  warm  water.  In  slight  cases  some  form  of 
paste  may  be  recommended. 

1$ — Acidi  carbolici n\ij 

Zinci  oxidi 5j 

Talci 5j 

Vaselini 3ij — M. 

Careful  puncture  of  the  large  blebs  will  give  much  com- 
fort, as  will  also  the  occasional  washing  of  the  affected 
parts  with  a  little  warm  water  or  a  weak  alkaline  lotion. 
The  washing  and  subsequent  gentle  drying  may  be  done 
with  absorbent  cotton. 

1  See  Section  II,  Liniments. 


184  INFLAMMATIONS 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Sodii  hyposulphitis 5j 

Glycerim 3ss 

Aquae q.  s.  ad  Sviij — M. 

Munro. 

1$ — Extract!  grindeliae  fl foj~5ij 

Aquse 5iv — M. 

S. — Apply  on  cloths.  Duhring. 

1$ — Tr.  sanguinariae, 

Aquae aa  5ij — M. 

S. — Paint  on. 


DERMATITIS  CALORICA. 

The  effects  on  the  skin  of  varying  degrees  of  heat  and 
cold  are  included  under  this  head,  as,  for  example,  sunburn, 
common  burns  and  scalds,  frostbites,  and  chilblains.  The 
clinical  symptoms  are  very  similar  in  these  affections, 
whether  the  exciting  agent  be  heat  or  cold,  and  there 
may  be  present  all  grades  of  disturbance  from  simple 
hyperemia  up  to  gangrene  of  the  skin.1 

Treatment. — The  treatment  of  a  burn  of  the  first  degree, 
namely,  that  condition  in  which  there  is  redness,  heat,  and 
swelling  with  considerable  pain,  followed  by  desquama- 
tion,  should  be  of  a  soothing  character.  A  saturated 
solution  of  sodium  bicarbonate  applied  by  means  of  cloths 
of  suitable  size  is  an  excellent  and  convenient  remedy. 

1  A  not  uncommon,  but  generally  unrecognized,  form  of  frost- 
bite, which  occurs  in  very  young  children,  has  been  reported  by 
one  of  us.  (Hardaway,  St.  Louis  Courier  of  Medicine,  March,  1904.) 
The  parts  attacked  are  the  cheeks  and  the  neck  under  the  chin, 
in  other  words  the  regions  that  are  usually  uncovered.  Upon 
a  superficial  examination  the  affected  area  presents  a  fairly  well- 
defined  flush  looking  like  an  ordinary  erythema,  but  upon  closer 
inspection  it  will  be  found  that  the  flush  area  corresponds  to  a 
deep  infiltration  of  the  tissues,  which  upon  manipulation  gives  the 
impression  of  an  embedded,  solid,  but  circumscribed  mass.  There  is 
usually  some  fever  and  enlargement  of  the  contiguous  lymphatic 
glands.  Most  of  the  children  attacked  have  fair  hair  and  skin.  The 
treatment  consists  in  the  application  of  the  modified  diachylon 
ointment,  stiffened  with  about  12  per  cent,  of  zinc  oxide. 


DERMATITIS  CALORIC  A  185 

Later  on,  in  the  desquamative  stage,  a  soothing  ointment 
may  be  employed.  In  burns  of  the  second  degree,  where 
blisters  have  formed,  the  contents  of  the  blebs  may  be 
evacuated,  taking  care,  however,  to  leave  the  roof  of  the 
blisters  intact,  as  they  form  the  best  protection  to  the 
inflamed  tissues  beneath.  The  carron  oil  (equal  parts  of 
lime-water  and  linseed  oil),  to  which  may  be  added  a 
small  amount  of  creosote,  is  probably  the  best  local 
application.  A  number  of  substances,  which  often  lie 
ready  at  hand,  are  useful  for  first  aid;  among  these  are, 
cotton-wool,  flour,  molasses,  white,  lead  paint,  varnish, 
common  soap  made  into  a  thick  lather,  and  mashed  pota- 
toes. Fluidextract  of  hammamelis  is  good.  Lister  covered 
the  surface  with  lint  soaked  in  3  per  cent,  carbolized  oil ; 
over  this  he  put  carbolized  gauze  covered  with  rubber 
tissue  or  oiled  silk,  and  a  bandage.  The  gauze  is  changed 
as  often  as  necessary,  but  the  lint  is  not  disturbed.  In  burns 
of  the  first  degree  Leistikow  uses  5  parts  zinc  oxide,  10  parts 
magnesium  carbonate,  and  from  1  to  2  parts  ichthyol ;  in 
burns  of  the  second  degree  he  applies  the  following:  zinc 
oxide,  5  parts;  prepared  chalk,  10  parts;  starch,  10  parts; 
linseed  oil,  10  parts;  lime-water,  10  parts,  and  from  1  to  3 
parts  of  ichthyol.  Picric  acid  was  originally  recommended 
by  Thierry,  and  has  been  much  used  of  late.  Keen  advo- 
cates compresses  soaked  in  the  normal  salt  solution. 

Continuous  immersion  in  a  warm  bath  is  a  valuable 
measure  in  extensive  cases  with  shock.  However,  these  and 
profound  burns  with  their  complications  and  after-results 
rather  belong  to  the  province  of  the  surgeon.  Opium  is 
always  indicated,  and,  generally,  alcohol.  The  body  tem- 
perature must  be  carefully  maintained  by  hot  bottles  and 
blankets. 

In  inflammation  of  the  skin,  the  result  of  cold,  the  patient 
should  be  placed  in  a  cool  room,  and  the  affected  parts 
should  be  restored  to  a  normal  temperature  by  being 
rubbed  with  snow,  or  else  by  the  application  of  cold  water. 
Sloughing  and  ulceration  should  be  managed  on  anti- 
septic principles. 


186  INFLAMMATIONS 

The  treatment  of  chilblains  has  been  given  in  another 
place  (p.  22). 

X-RAY  DERMATITIS. 

For  description  of  x-ray  dermatitis,  the  reader  is  referred 
to  Part  II. 

Treatment. — The  treatment  of  the  mild  grades  of  x-ray 
irritation  is  that  of  erythema  in  general,  viz.,  soothing 
lotions,  pastes,  and  salves.  We  have  found  the  zinc  and 
calamine  lotion,  with  or  without  a  little  carbolic  acid,  an 
agreeable  application.  The  same  may  be  said  of  Pick's 
linimentum  exsiccans  reinforced  with  10  per  cent,  of  zinc 
oxide.  In  cases  of  decided  dermatitis,  Crocker's  liniment 
thus  modified  is  more  suitable : 

ty — Zinci  oxidi 5ss 

Pulv.  calaminse  praep 9j 

Liq.  calcis, 

Ol.  amygdalae aa  3j 

Lanolini 5jss — M. 

S. — Apply  on  strips  of  cotton  cloth. 

Mewborn  recommends  the  following  application: 

1^ — Plumbi  acetatis 5iv 

Aquae Oiij 

Solve  et  adde 

Alumen  sulph.         Sijss 

Sodium  sulph Siijss 

Aquam Ov — M. 

For  very  sensitive  cases,  Pusey  finds  dressings  moistened 
with  normal  saline  solution  least  irritating,  although  some 
of  his  cases  did  better  with  berated  cold  cream  applied  on 
gauze. 

For  the  chronic  scaling  inflammation  of  the  hands,  wo 
have  used  with  some  success  the  5  per  cent,  salicylic  acid 
plaster  mentioned  on  p.  93.  It  should  be  spread  on  strips 
of  cotton  cloth  and  bound  neatly  on  the  parts  affected. 

In  similar  cases  with  telangiectases,  hyperkeratoses  etc., 
Unna  recommends  bathing  the  part  with  a  hot  decoction 
of  arnica,  followed  by  the  application  of  diachylon 
ointment. 


X-RAY  DERMATITIS  187 

Deep  ulcerations  tax  one's  resources  to  the  utmost. 
Stel wagon  has  seen  the  pain  relieved  by  orthoform  in  the 
proportion  of  1  or  2  drachms  to  1  oz.  of  excipient,  but  in 
several  cases  under  our  care  nothing  has  availed  short  of 
morphine.  Several  ingenious  methods  have  been  devised. 
Thus,  Bar  obtained  healing  of  an  ulcer  on  the  abdomen  by 
exposing  it  for  several  hours  every  day  to  the  light  of  the 
sun,  a  box  being  fitted  over  the  whole  abdomen,  the  cover 
of  the  box  consisting  of  a  pane  of  red  glass  which  was  two 
inches  from  the  surface.  Belot  obtained  a  rapid  result  with 
a  red  lamp.  Freund  and  Ehrmann  obtained  relief  of  pain 
and  speedy  cicatrization  with  a  100  candle-power  incandes- 
cent electric  light,  applied  for  one-half  hour  at  a  time.  The 
electric  effleuve  has  been  successful,  Apostoli  using  a  static 
machine,  and  Oudin  a  resonator  for  ten  minutes,  three 
times  a  week.  Schwartz  healed  an  ulcer  of  eight  months' 
duration  by  electric  baths,  using  a  weak  continuous  cur- 
rent. These  cases  ordinarily  require  deep  curetting  or, 
better,  excision,  followed  by  skin  grafting. 


HEMORRHAGES. 

PURPURA. 

Description. — Purpura  is  characterized  by  the  appearance 
in  the  skin  of  variously  sized  and  shaped  hemorrhagic 
lesions  that  do  not  fade  on  pressure.  The  cutaneous 
symptoms  may  be  accompanied  by  bleeding  from  the 
mucous  surfaces  and  extravasations  into  the  viscera. 
According  to  the  form,  shape,  and  other  circumstances 
connected  with  the  cutaneous  hemorrhage,  the  resulting 
lesions  have  received  certain  special  designations,  as 
petechiae,  vibices,  ecchymoses,  etc. 

Purpura  Simplex. — This  is  the  most  trivial  of  the  cutane- 
ous hemorrhages.  The  general  health  is  often  apparently 
unaltered,  although  at  times  some  degree  of  malaise  may 
be  experienced,  with  slight  elevation  of  temperature.  The 
eruption,  so  to  speak,  may  consist  of  any  of  the  forms  just 
mentioned,  but  is  for  the  most  part  petechial  in  character, 
or  occurs  in  bands,  streaks,  or  with  a  circinate  arrangement 
(Duhring).  Any  part  of  the  body  may  be  attacked,  but 
the  lower  limbs  perhaps  suffer  oftenest.  The  lesions  come 
out  in  successive  crops,  and  the  disorder  may  be  prolonged 
for  a  considerable  period  in  this  way.  Each  hemorrhagic 
spot  will  last  for  a  week  or  two,  and  will  undergo  the  usual 
changes  of  color,  e.  g.,  crimson,  purple,  blue,  yellow,  green, 
etc.  The  eruption  itself  occasions  no  discomfort. 

Purpura  Hsemorrhagica. — Hemorrhagic  purpura  (land 
scurvy,  morbus  maculosus  Werlhofii)  may  be  said  to  be  a 
severe  form  of  the  simple  variety,  sometimes,  in  fact, 
developing  out  of  it,  and  adding  to  its  cutaneous  features 
bleeding  from  the  mucous  outlets,  and  in  some  cases 
exhibiting  extravasations  into  serous  membranes  and 
important  viscera.  It  is  usually  unaccompanied  by  rise 
of  temperature,  and  may  develop  suddenly;  or,  on  the 


PURPURA  189 

other  hand,  it  may  be  preceded  for  a  short  period  by  head- 
ache, loss  of  appetite,  vague  pains,  lassitude,  and  other 
symptoms  of  indefinite  ill-being. 

Hemorrhage  into  the  cranial  cavity  may  cause  a  speedy 
death,  and  in  the  malignant  cases  the  acute  loss  of  blood 
will  more  or  less  rapidly  lead  to  a  fatal  issue.  In  other 
instances  the  bleeding  is  more  moderate  and  the  patient  is, 
after  a  season,  restored  to  health;  relapses,  however,  being 
not  uncommon. 

Purpura  Rheumatica. — The  eruption  is  generally  pre- 
ceded by  a  varying  degree  of  malaise,  and  the  patient 
complains  of  pains  in  the  joints  of  a  rheumatic  character, 
and  on  inspection  the  tissues  about  the  joints  are  found  to 
be  somewhat  edematous  and  slightly  tender.  The  hemor- 
rhagic  spots,  generally  petechiae,  appear  in  a  day  or  two 
from  the  beginning  of  the  affection,  although  in  some 
instances  this  order  is  reversed,  and  the  pains  in  the  joints 
follow  after  the  purpuric  lesions.  The  usual  situation  of 
the  eruption  is  on  the  lower  extremities.  The  cutaneous 
hemorrhages  undergo  absorption  in  the  course  of  time, 
presenting  in  the  process  of  involution  the  various  shades 
of  yellow,  green,  blue,  etc.  The  disorder  may  subside 
after  one  attack,  but  relapses  are  not  uncommon.  Among 
the  rare  complications  may  be  mentioned  bleeding  from 
mucous  membranes,  albuminuria,  valvular  murmurs,  or 
the  supervention  of  purpura  hsemorrhagica  (Scheby-Buch). 
Purpura  rheumatica  is  said  to  occur  in  young  people  of 
both  sexes,  but  especially  in  young  women.  There  also 
exists  a  severer  grade  of  arthritic  purpura,  in  which  the 
eruption  is  not  limited  to  the  lower  limbs  and  the  joint 
affections  are  more  marked,  and  there  are  also  pronounced 
gastro-intestinal  symptoms,  together  with  lesions  of  the 
throat.  There  may  be  present  besides,  urticaria  and 
edema  of  the  skin,  and  multiform  erythema.1  Henoch 
and  Couty  have  directed  attention  to  a  form  of  purpura 
occurring  chiefly  in  children,  in  which  there  are  rheumatic 

1  See  Osier,  American  Journal  Medical  Sciences,  December,  1895. 


190  HEMORRHAGES 

pains,  intestinal  pain  and  vomiting,  and  the  establishment 
of  considerable  edema  of  the  skin.1 

In  addition  to  the  forms  of  purpura  considered  above, 
and  which  have  been  regarded  as  idiopathic,  there  are  a 
large  number  of  cutaneous  hemorrhages  that  are  unequivo- 
cally secondary  in  character,  viz.,  the  hemorrhages  that 
complicate  various  infectious  diseases,  those  due  to  the 
ingestion  of  certain  drugs  (potassium  iodide),  and  those 
arising  from  debility,  from  cardiac  affections,  etc. 

In  what  may  be  called  the  essential  purpuras  the  etiology 
is  far  from  clear.  That  these  various  forms  of  purpura  are 
of  an  infectious  nature  is  more  than  probable. 

Prognosis. — A  guarded  prognosis  is  required  in  all  cases 
of  purpura,  as  the  course  and  possible  complications  of 
even  simple  cases  are  not  always  easy  to  foretell.  It  must 
be  said,  however,  that  the  simple  forms  usually  terminate 
favorably,  although  interrupted  by  a  number  of  relapses. 
Purpura  hsemorrhagica  will  very  naturally  occasion  much 
anxiety,  both  on  account  of  the  possibility  of  a  fatal  issue, 
and  also  from  the  fact  that  cases  finally  ending  in  recovery 
may  be  prolonged  by  repeated  recurrences. 

Treatment. — Mild  cases  of  purpura  require  no  particular 
treatment  of  any  sort.  The  careful  physician  will,  as  a 
general  principle,  always  endeavor  to  get  at  the  cause  of 
the  hemorrhage  and  remove  it  if  possible.  In  this  con- 
nection we  should  remember  that  purpura  is  in  most 
cases  a  symptom  merely,  and  not  an  essential  disease.  In 
simple  purpura  in  children,  however,  and  in  cases  with 
mild  arthritic  symptoms,  Osier  gives  arsenic  to  the  limit  of 
tolerance. 

In  all  grave  forms  of  purpura  it  is  of  the  utmost  impor- 
tance to  keep  the  patient  flat  on  his  back.  Among  the  drugs 
of  most  repute  in  purpura  may  be  mentioned  turpentine, 
acetate  of  lead,  dilute  sulphuric  acid,  ergot,  quinine,  and 
gallic  acid.  Nitrate  of  silver  has  recently  been  recom- 

1  We  believe  that  one  of  us  (Hardaway)  was  the  first  to  demon- 
strate the  existence  of  the  plasmodium  malarite  in  some  of  these 
cases.  See  Manual  of  Skin  Diseases,  1898. 


PURPURA  191 

mended,  as  also  chloride  of  calcium,  15  to  30  gr.,  three 
times  daily,  but  not  longer  than  three  days  at  a  time,  and 
adrenalin  chloride  (McGowan).  Unna  gives  the  tincture  of 
arnica  internally,  in  the  dose  of  5  to  15  drops,  three  times 
a  day.  In  malarial  cases  quinine  is  urgently  demanded. 
Gelatin  subcutaneously  or  by  the  mouth  has  also  been 
employed  in  severe  forms  of  purpura  with  success.  A  com- 
bination of  ergot  and  iron  has  usually  given  us  the  best 
results  in  cases  suitable  for  their  administration.  In  grave 
cases  the  ergot  should  be  given  hypodermically.  The 
local  hemorrhages  should  be  checked  in  the  usual  way, 
that  is  by  astringents,  adrenalin,  tampons,  pluggings,  etc. 
In  rheumatic  types  the  salicylates  may  be  administered, 
and  pains  in  the  joints  combated  by  ichthyol  or  iodine 
salves,  cotton  compresses,  etc.  Constitutional  symptoms 
should  be  treated  on  general  principles.  Tonics,  like  qui- 
nine, strychnine,  arsenic,  are  useful  during  convalescence. 
Iron  is  said  to  be  contra-indicated  for  fear  of  producing 
relapse,  but  it  may  be  given  later.  According  to  Lock- 
wood,  if  profound  anemia  should  supervene,  warmth  must 
be  applied  to  the  body,  hot  applications  to  the  heart,  and 
opium  administered  in  small,  repeated  doses.  The  same 
authority  recommends,  under  similar  circumstances,  inhala- 
tions of  pure  oxygen  gas,  and  rectal  or  hypodermic  injec- 
tions of  a  warm,  sterilized  saline  solution.  On  theoretical 
grounds,  at  least,  the  administration  of  calcium  salts  would 
seem  proper.  In  a  case  of  the  so-called  Henoch's  purpura, 
Longley  gave  a  girl,  aged  eleven  years,  adrenalin,  2 
minims;  liq.  arsenicalis,  3  minims,  every  four  hours,  with 
marked  success. 


ADDITIONAL  PRESCRIPTION. 

1$ — Ext.  flor.  arnicas 3ss 

Ergotinse, 

Quinmte  hydrochlor., 

Ferri  redacti aa     gr.  xlv — M. 

Ft.  pil.  No.  100. 

S. — Two  pills  twice  daily  as  a  tonic.  Leistikow. 


HYPERTKOPHIES. 

LENTIGO. 

Description. — Ephelides,  or  popularly  freckles,  are  small 
patches  of  pigment,  of  a  yellow  or  even  blackish  color,  and 
varying  in  size  from  a  pin's  head  to  a  split  pea.  They 
affect  mostly  the  face  and  backs  of  the  hands,  but  are  also 
to  be  found  on  the  covered  parts  of  the  body.  A  similar 
condition  is  observed  in  an  early  stage  of  angioma  pig- 
mentosum  et  atrophicum,  and  also  in  aged  people.  Wilson 
speaks  of  congenital  cases,  but,  as  a  rule,  freckles  do  not 
develop  until  the  child  is  of  some  age — six  to  seven  years — 
and  then  continue  more  or  less  marked  throughout  life. 
Persons  of  blonde  complexion  are  more  subject  to  freckles 
than  those  of  darker  skin.  It  is  commonly  believed  that 
the  sunlight,  especially  in  summer,  is  the  immediate  excit- 
ing cause,  and  we  know  that  freckles  disappear,  or  at  least 
notably  fade  in  winter;  but  they  also  occur  on  those  parts 
of  the  body  not  exposed  to  the  sun's  rays,  the  so-called 
"cold  freckles"  which  Unna  regards  as  small  pigmentary 
nevi. 

Treatment. — As  prophylactic  measures  the  wearing  of 
gloves  and  red  or  light-brown  veils  have  been  suggested. 
Many  remedies  have  been  recommended  for  the  temporary 
removal  of  freckles.  The  following  ointment  is  one  of  the 
most  successful: 

1^ — Hydrarg.  ammoniati, 

Bismuth!  subnitratis aa  3j 

Ung.  aq.  rosae 3j — M. 

S. — Apply  at  night. 

If  the  patient  is  prepared  to  undergo  the  confinement  and 
trouble,  the  shelling  of  the  skin  with  resorcin  paste  (see 
acne)  is  more  rapid,  but  we  should  hesitate  to  advise  the 
procedure.  With  this  same  end  in  view  Stelwagon's  plan 


CHLOASMA  193 

is  safer,  namely,  wearing  constantly  for  five  or  ten  days  a 
10  to  25  per  cent,  salicylic  acid  plaster,  the  application 
being  replaced  when  it  loosens.  Stevens  recommends 
lactic  acid  in  the  proportion  of  1  part  of  the  acid  to  from  5 
to  20  parts  of  water. 

Peroxide  of  hydrogen,  pure  or  diluted,  has  also  been 
suggested,  but  we  have  seen  but  little  practical  benefit  from 
it.  As  is  well  known,  the  various  patent  freckle  removers 
contain  bichloride  of  mercury,  but  even  in  the  hands  of  the 
experienced  physician  the  strong  mercurial  lotions  are 
objectionable.  However,  two  formulse  containing  mercury 
will  be  found  below. 

Some  of  the  "  freckle  soaps"  are  useful  in  mild  cases,  or 
they  may  be  used  in  conjunction  with  the  bismuth  and 
white  precipitate  salve  given  above.  For  the  very  black 
freckles  we  have  found  it  a  good  plan  to  touch  each  one 
quite  superficially  with  a  stiff,  fine  needle,  attached  to  the 
negative  pole  of  a  galvanic  battery. 

ADDITIONAL  PRESCRIPTIONS. 

!$ — Hydrarg.  chloridi  corros gr.  iv-viij 

Tr.  benzoin! 5ij 

Zinci  sulphatis gr.  xx-xl 

Alcoholis, 

Aquae q.  s.  ad  5iv — M. 

S. — External  use.  Stelwagon. 

1^ — Hydrarg.  chlor.  corrosiv gr.  v-xx 

Ammonii  chlorid.  pur 5ss 

Mist,  amygdalae  amar 3iv — M. 

Bulkley. 

CHLOASMA. 

Description. — By  the  term  chloasma  is  understood  an 
abnormal  discoloration  of  the  skin  occurring  generally  in 
patches  of  brown,  yellow,  or  black,  and  presenting  various 
shapes  and  sizes.  Chloasma  is  usually  divided  into  the 
idiopathic  and  symptomatic  varieties.  Idiopathic  chloasma 
is  due  to  external  causes,  viz.,  mechanical,  chemical, 
13 


194  HYPERTROPHIES 

thermal,  parasitic.  Symptomatic  chloasma  may  be  a 
sequel  of,  or  accompany,  various  physiological  or  pathologi- 
cal conditions  of  the  system,  namely,  pregnancy,  ovarian 
and  uterine  diseases,  diseases  of  certain  glands  (the  supra- 
renal and  thyroid),  tuberculosis,  cancer,  lymphoma,  leprosy, 
malaria,  syphilis,  and  is  often  seen  after  the  long-continued 
use  of  arsenic.  Chronic  constipation  and  intestinal  and 
gastric  fermentation  are  more  frequently  the  causes  of  a 
patchy  pigmentation  of  the  face  and  hands  than  is  usually 
supposed.  Diseases  of  the  liver,  while  exceptionally  accom- 
panied by  a  limited  or  diffused  pigmentation,  more  often 
produce  jaundice,  so  that  the  term  "liver  spot"  is  not 
well  chosen. 

Prognosis. — Chloasma  is  the  result  of  so  many  different 
conditions  that  it  is  difficult  to  forecast  its  amenability  to 
treatment.  So  far  as  the  type  ordinarily  encountered  is 
concerned,  it  may  be  said  that  recurrence  is  common  after 
removal,  and,  occasionally,  the  pigmentation  is  increased; 
on  the  other  hand,  the  cause  of  the  discoloration  having 
either  spontaneously  disappeared  or  yielded  to  treatment, 
the  chloasma  may  also  vanish. 

Treatment. — The  internal  treatment  of  chloasma  consists 
principally  in  removing  the  condition  upon  which  it  is 
dependent.  In  all  cases  of  pigmentation  of  the  face  and 
neck,  and  it  is  mostly  for  such  blemishes  that  the  derma- 
tologist is  consulted,  the  uterus  and  ovaries  should  be 
examined,  as  well  as  the  condition  of  the  bowels  and 
stomach. 

The  result  from  local  treatment  will  depend  upon  the 
depth  and  location  of  the  pigment.  The  remedies  pre- 
scribed cause  desquamation  of  the  epidermis,  in  this  way 
removing  the  pigmented  cells.  There  are  innumerable 
prescriptions  recommended  for  topical  use,  but  we  shall 
limit  ourselves  to  the  measures  that  we  have  found  most 
practical.  Nightly  friction  with  green  soap  is  often  bene- 
ficial, or  the  white  precipitate  and  bismuth  salve,  given 
under  freckles,  may  be  applied  at  night  and  washed  off  in 
the  morning  with  the  tincture  of  green  soap,  which  latter 


CHLOASMA  195 

consists  of  equal  parts  of  alcohol  or  cologne  and  green 
soap.  If  a  more  decided  effect  is  desired,  the  various 
scaling  processes  may  be  tried,  but  it  is  a  safe  plan  to  feel 
one's  way  with  weak  preparations  at  first.  Among  the 
preparations  recommended  may  be  mentioned  resorcin 
in  from  10  to  20  per  cent,  solution  in  alcohol,  or  in  paste, 
and  salicylic  acid.  Galloway  says  that  the  last-named 
drug  in  plaster,  plaster-mull,  or  paste  form  applied  for 
twenty-four  hours  at  a  time,  or  as  a  saturated  solution  in 
alcohol,  applied  repeatedly  for  several  hours,  is  one  of  the 
safest  and  most  efficacious  remedies  for  extensive  patches. 
This  is  our  own  experience,  but  we  should  always  give  the 
preference  to  the  bismuth  and  white  precipitate  salve  for 
first  trial.  We  have  the  idea,  moreover,  that  the  rapid 
removal  of  the  pigmentation  is  more  apt  to  be  followed  by 
return  of  the  discoloration  than  when  the  slower  methods 
are  employed. 

Corrosive  sublimate  in  various  strengths  and  combina- 
tions is  in  common  use.  Bulkley,  for  example,  advises  the 
following: 

1$ — Hydrarg.  chlor.  corrosiv gr.  iij-xij 

Zinci  sulphatis, 

Plumbi  acetatis aa  5ss 

Aquae  destillatae q.  s.  ad  §iv — M. 

S. — External  use,  night  and  morning. 

J.  C.  White  sometimes  prescribes  this  combination: 

1$ — Hydrarg.  chloridi  corrosiv.      .      .      .      .      .  gr.  vj 

Acidi  muriatici  diluti 3j 

Glycerin! 5j 

Alcoholis, 

Aquae  rosse aa  5ij 

Aquae  destillatae 5iv — M. 

S. — Apply  at  night  and  wash  off  with  soap  and  water  in  the 
morning. 

Peroxide  of  hydrogen,  pure  or  diluted  at  first,  is  also 
recommended.  It  should  be  applied  on  cotton  and 
allowed  to  remain  on  the  spot  several  minutes.  This 
procedure  may  be  repeated  several  times  a  day.  We  do 
not  regard  this  method  as  of  much  value. 


196  HYPERTROPHIES 

Small  areas  may  be  removed  by  electrolytic  puncture, 
taking  care  that  the  needle  should  be  inserted  very  super- 
ficially. (See  Lentigo.)  Trichloracetic  acid  barely  brushed 
over  the  surface,  and  not  allowed  to  run  over  the  contigu- 
ous skin,  and  carbolic  acid  similarly  employed,  are  useful 
in  limited  patches.  In  all  the  text-books  Hebra's  rapid 
method  of  removing  chloasma  with  strong  lotions  of  cor- 
rosive sublimate  is  referred  to  and  recommended.  We  have 
seen  the  most  mischievous  results  from  this  practice  and 
would  earnestly  warn  against  its  adoption. 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Ammonii  chloridi 3ss 

Aq.  cologniensis §j 

Aquae  destillatse Sviij — M. 

S.— External  use.  J.  C.  White. 

IJ — Hydrarg.  ammoniati, 

Sodii  boracis aa  5ss 

Ol.  rosmarini gtt.  x 

Ung.  simplicis 5  j 

S. — Local  use.  Kaposi. 

1$ — Bismuth!  chloridi 3j 

Hydrarg.  subchlpridi    .  gr.  J 

Hydrogen  peroxidi  (10-vol.  sol.)  .     5j 

Adipis  l:in:r, 

Vaselini aa    3iv — M. 

S. — External  use.  Unna. 

1$ — Hydrarg.  chlor.  corrosiv gr.  ij 

Tr.  benzoin 5ss 

Mi i mis.  amygdalae 5j — M. 

S. — External  use.  Duhring. 


TATTOO  MARKS  AND  POWDER  STAINS. 

Tattooing  consists  in  the  introduction  of  some  insoluble 
pigment  into  the  upper  layers  of  the  skin  so  as  to  form  a 
patriotic,  religious,  or  erotic  design,  or  letters,  usually  the 
wearer's  initials  or  a  feminine  name.  India  ink,  gun- 


TATTOO  MARKS  AND  POWDER  STAINS         197 

powder,  or  indigo  are  used  for  the  blue  colors,  and  carmine 
or  cinnabar  for  the  red.  These  preternatural  adornments 
are  usually  acquired  in  youth.  Later  the  wisdom  which 
sometimes  comes  with  age,  the  achievement  of  an  improved 
social  position,  or  marriage,  may  make  their  possession  an 
embarrassment  and  their  removal  desirable. 

Powder  stains  differ  only  in  the  absence  of  design  in 
their  production  and  execution.  They  are  more  often  about 
the  face,  where  they  sometimes  form  a  serious  disfigurement. 

Treatment. — Tattoo  marks  several  inches  across  may  be 
treated  by  excision  followed  by  grafting.  Smaller  marks 
may  be  removed  by  the  cutaneous  punch  or  electrolysis. 
The  method  by  scarification  followed  by  the  application  of 
papoid  or  caroid  has  been  an  absolute  failure  in  our  hands. 
Cauterization  is  efficient,  but  leaves  an  undesirable  scar. 
Brault,  after  thorough  cleansing  of  the  surface,  tattoos  in 
a  solution  of  30  parts  of  zinc  chloride  in  40  parts  of  water. 
This  excites  a  superficial  destructive  inflammation.  Variot 
rubs  on  a  concentrated  solution  of  tannin;  this  is  then 
tattooed  in.  The  silver  stick  is  then  rubbed  firmly  on, 
and  after  a  few  minutes'  interval  the  surface  wiped  off. 
There  is  inflammation  and  a  crust  forms,  which  comes  off 
in  a  week  or  two. 

Powder  Stains. — Treatment  varies  according  as  the  case 
is  seen  within  a  few  hours  after  the  accident  or  later. 
Within  the  first  twenty-four  hours  or  so  a  number  of  the 
grains  can  be  picked  out  with  a  blunt  knife  point  or  small 
curette.  We  employ  the  minute  instrument  designed  for 
the  ophthalmologist.  Many  grains  will  already  have  dis- 
integrated into  a  thickish,  inky  fluid  which  can  be  washed 
out,  together  with  some  still  solid  particles,  by  a  forcible 
stream  from  a  hypodermic  syringe.  Crile,  Rhoads,  and 
Clark  advocate  the  use  of  hydrogen  peroxide  solution  kept 
constantly  applied  on  lint.  A  white  zone  forms  around  and 
under  the  powder  grain,  which  may  then  be  easily  lifted 
out.  If  any  considerable  part  of  the  face  is  involved,  the 
best  procedure,  within  the  first  twelve  hours,  is  the  fol- 
lowing: The  patient  is  placed  under  a  general  anesthetic 


198  HYPERTROPHIES 

and  the  surface  thoroughly  scrubbed  with  a  nail-brush, 
frequently  stopping  to  douche  off  the  surface  and  clean  the 
brush.  Of  course,  strict  aseptic  precautions  should  be 
employed.  A  simple  dressing  must  be  applied  for  the  next 
several  ensuing  days.  The  day  following  the  accident 
there  may  be  so  much  inflammatory  reaction  as  to  interdict 
further  attempts  to  dig  out  the  grains.  After  the  first  two 
or  three  days,  such  attempts  will  be  useless,  as  the  black 
specks  no  longer  indicate  the  presence  of  grains,  these 
having  disintegrated,  but  are  henceforth  due  to  staining  of 
the  tissues.  We  may,  therefore,  as  well  await  the  subsid- 
ence of  inflammation,  and  then  proceed  as  with  tattoo 
marks.  The  only  successful  methods  are  those  directed 
to  the  destruction  of  small  portions  of  tissue,  and  of  these 
electrolysis  has  been  most  satisfactory  in  our  hands. 

A  much  less  heroic,  and  sometimes  very  successful 
method,  in  recent  cases,  consists  in  applying  on  strips  of 
cotton  cloth  a  5  per  cent,  salicylated  soap  plaster  (see 
formula  on  p.  93)  to  the  affected  region,  the  whole  being 
kept  in  place  by  a  suitable  bandage.  After  about  twelve 
hours  a  large  number  of  the  powder  grains  can  be  scraped 
away  with  a  blunt  curette.  These  applications,  which  are 
also  soothing  to  the  inflamed  skin,  may  be  repeated  for 
several  days  in  succession.  If  the  skin  is  very  acutely 
inflamed,  the  unguentum  vaselini  plumbicum  may  be 
applied  in  a  similar  manner  for  the  first  day,  and  followed 
later  by  the  plaster  mentioned  above. 


KERATOSIS   PILARIS. 

Description. — The  disease  known  as  keratosis,  or  lichen 
pilaris,  is  characterized  by  the  presence  of  numerous,  small, 
papular  elevations  seated  about  the  mouths  of  the  hair 
follicles.  The  disorder  occurs  almost  exclusively  on  the 
outer  surfaces  of  the  arms  and  thighs,  and  is  made  up  of 
small,  whitish,  or  dirty-looking  papules  often'pierced  by  a 
hair;  but  sometimes  when  the  horny  accumulation  has 


KERATOSIS  PALMARIS  ET  PLANTARIS         199 

been  picked  out,  the  hair  may  be  seen  coiled  up  under  it. 
At  times  the  papules  are  quite  red,  and  here  and  there  pus- 
tules may  be  observed.  Usually  the  intervening  skin  is 
normal,  but  at  times  rough  and  scaly.  Considerable  pru- 
ritus is  present  in  some  cases.  It  is  most  common  in  the 
winter  season. 

Brocq  divides  keratosis  pilaris  into  several  varieties 
according  to  the  color,  intensity,  and  location  of  the  lesions. 
He  also  describes  a  keratosis  pilaris  of  the  face  which 
terminates  in  interfollicular  atrophy. 

People  who  are  chary  in  the  use  of  soap  and  water  are 
the  usual  sufferers  from  keratosis  pilaris;  but  it  should 
be  well  understood  that  many  perfectly  clean  persons 
develop  this  trouble  after  puberty,  and  that  it  is  a  common 
accompaniment  of  ichthyosis. 

Treatment. — In  cases  due  to  uncleanliness,  vigorous  use 
of  soap  and  water  will  speedily  effect  a  cure.  Hyde  and 
Montgomery  recommend  daily  cold  or  saline  baths,  fol- 
lowed by  brisk  friction,  systematically  carried  out  for 
years.  In  other  instances  the  plan  suggested  for  ichthyosis, 
viz.,  hot  alkaline  baths,  or  warm  baths  with  green  soap 
frictions,  preceded  and  followed  by  inunctions  of  bland 
salves,  will  give  the  best  results.  In  poorly  nourished 
persons,  cod-liver  oil,  arsenic,  and  iron  are  useful  adjuncts 
to  the  local  measures. 


KERATOSIS  PALMARIS  et  PLANTARIS. 

Description. — Aside  from  the  familiar  callosities  affecting 
the  palmar  and  plantar  surfaces,  and  due  to  external 
pressure,  there  are  a  considerable  number  of  affections 
characterized  by  hypertrophy  of  the  horny  layer  of  those 
parts,  although  possessing  a  widely  varied  etiology. 

The  horny  thickenings  occurring  in  connection  with 
eczema,  psoriasis,  and  syphilis,  are  well  recognized.  Less 
common  are  the  warty  growths  following  the  ingestion  of 
arsenic  and  usually  associated  with  hyperidrosis.  The 


200  HYPERTROPHIES 

papules  form  first  around  the  sweat  orifices,  but  after  a 
while  the  intervening  spaces  become  involved  and  a  general 
thickening  takes  place.  Many  cases  of  tylosis  are  con- 
genital, and  it  may  appear  in  several  generations  and 
attack  several  members  of  a  family. 

Under  the  name  of  keratodermia  erythematosa  sym- 
metrica,  Besnier  describes  a  case  in  which  there  was  a 
symmetrical  thickening  of  the  horny  layer,  disposed  in 
islets  on  the  palmar  surfaces  of  all  the  fingers  and  toes,  and 
on  the  prominences  of  the  palms  and  soles.  The  skin 
between  the  hyperkeratosic  lesions  was  healthy  and*  was 
separated  from  the  diseased  parts  by  an  erythematous  zone 
of  from  5  to  6  mm.  in  breadth. 

As  an  erythema  keratodes,  Brooke  has  described  a 
defined,  chronic  erythema  of  the  palms  and  soles  which  was 
followed  by  a  superficial  hyperkeratosis,  associated  with 
tenderness  and  edema.  It  recovers  readily  under  treat- 
ment, but  is  prone  to  relapse. 

Treatment. — In  the  way  of  internal  treatment,  arsenic, 
ichthyol,  and  pilocarpine  have  been  advised  by  some 
authorities,  but  the  efficacy  of  such  treatment  seems  to 
us  doubtful. 

Local  measures,  however,  are  capable  of  giving  at  least 
temporary  relief,  and  should  consist  of  such  keratolytics 
as  salicylic  acid,  resorcin,  etc.  A  salicylic  acid  plaster  10 
to  20  per  cent,  strength,  or  a  solution  of  the  same  drug  in 
flexible  collodion,  £  drachm  to  1  oz.,  generally  suffices  to 
remove  the  thickened  epidermis.  After  the  removal  of  the 
horny  plates  the  skin  is  left  very  sensitive,  and  as  a  matter  of 
relief,  as  well  as  in  the  hope  of  delaying  a  recurrence  of  the 
process,  we  order  a  5  per  cent,  salicylated  soap  plaster, 
spread  on  cotton  cloth,  to  be  worn  constantly.  Sometimes 
the  emol  keleet  ointment  (see  p.  115)  serves  a  better 
purpose. 

Several  instances  of  relief  and  apparent  cure  have  been 
reported  as  the  result  of  the  application  of  the  or-rays. 
Zeisler  has  witnessed  a  cure  in  three  cases  by  this  method. 
Stelwagon  has  also  had  good  results.  It  is  possible  that 


KERATOSIS  SENILIS  201 

some  of  these  cases  have  the  same  etiology  as  callus,  viz., 
malposition  of  the  feet,  in  which  case  the  treatment  would 
be  obvious  (q.  u). 


KERATOSIS  SENILIS. 

Description. — Among  the  various  changes  incident  to  the 
old  age  of  the  skin,  the  most  common  and  the  most  impor- 
tant are  the  presence  upon  the  integument  of  freckle-like 
lesions,  brown  or  yellowish  brown  in  color,  pea-sized  or 
larger,  covered  with  greasy  scales  or  crusts;  and  the  more 
distinctly  keratotic  patches  which  are  somewhat  elevated 
and  covered  with  a  thick,  rough,  horny  layer.  Epithelio- 
matous  degeneration  often  occurs  as  a  sequel  to  these 
conditions.  The  face  and  backs  of  the  hands  are  the  usual 
sites  of  these  changes  in  the  skin,  and,  as  a  rule,  they  make 
their  appearance  somewhat  late  in  life,  but  often  the  skin 
suffers  a  premature  senility,  which  is  not  shared  by  the 
body  in  general. 

Treatment. — Anointing  the  parts  with  an  indifferent 
salve  overnight,  and  washing  it  off  in  the  morning  with  a 
bland  soap  like  the  emol  keleet,  is  usually  sufficient  treat- 
ment for  the  slight  seborrhoic  patches.  The  use  of  irri- 
tants and  caustics  is  to  be  deprecated.  If  the  coating  over 
the  lesions  be  rougher  and  more  adherent,  a  5  per  cent, 
salicylic  soap  plaster  (see  p.  93),  spread  on  cotton  cloth, 
and  worn  at  night,  or  in  some  cases  constantly,  gives  good 
results.  Rolie*  was  the  first  to  call  attention  to  the  value  of 
salicylic  acid  and  sulphur,  in  the  form  of  a  paste,  to  be 
applied  after  the  removal  of  the  crusts  or  scales : 

]$ — Acidi  salicylici gr.  x-xxx 

Sulphuris  prsecipitati 5ss 

Pulv.  amyli 5ss 

Ung.  aq.  rosae 5j — M. 

S. — Apply  in  a  thin  layer. 

D.  W.  Montgomery,  Stelwagon,  and  others  recommend 
an  ointment  of  sulphur  and  salicylic  acid  10  to  40  gr.  each 


202  HYPERTROPHIES 

to  1  oz.,  which  is  to  be  rubbed  in  gently  at  night,  or  morn- 
ing and  night.  We  generally  make  use  of  these  remedies 
after  the  patient  has  worn  the  plaster  for  some  time,  taking 
care,  however,  to  see  that  the  surface  to  which  the  lead  has 
been  applied  is  quite  free  of  that  drug  before  applying  the 
sulphur. 

Another  combination  that  is  useful  at  times  is  the 
following: 

R- — Resorcini gr.  v-x 

Sulphuris  praecip., 

Zinci  oxidi aa     3ss 

Pulv.  amyli, 

Vaselini, 

Lanolini aa     5j — M. 

S. — Apply  in  a  thin  layer. 

In  considerably  developed  patches,  that  is,  the  true  senile 
wart,  it  is  recommended  to  use  salicylic  acid  ointments, 
plaster  mulls  or  collodions,  in  the  strength  of  10  to  25  per 
cent.  After  the  removal  of  the  thick  covering  by  these 
means,  the  milder  pastes  and  salves  mentioned  above  may 
be  again  employed.  According  to  Sabouraud,  these  lesions 
improve  greatly  under  the  influence  of  reducing  ointments 
containing  chlorates : 

1$ — Potassii  chloratis gr.  xxiy 

Sulphuris  prsecipitati gr.  xlviij 


Resorcini 
Vaselini 


?.  xvi 
j-M. 


As  a  rule,  however,  we  think  that  these  palliative  meas- 
ures are  useless,  and  we  know  that  they  are  sometimes 
harmful,  and  the  wisest  course  is  to  let  these  growths  alone, 
or  else,  if  they  appear  threatening,  or  occupy  situations 
especially  prone  to  traumatism,  to  destroy  them  completely 
by  electrolysis.  We  have  used  electrolysis  in  this  way  for 
more  than  thirty  years  and  have  been  almost  invariably 
satisfied  with  the  results. 

In  the  common  wart  it  is  only  necessary  to  pass  the 
needle  superficially,  but  in  these  cases,  the  instrument — 
a  stout  one — must  be  repeatedly  passed  deeply  under  and 
through  the  growth  and  some  distance  on  all  sides  of  it. 


POROKERATOSIS  203 

Every  one  familiar  with  the  therapeutic  uses  of  the  or-ray 
has  noted  the  disappearance  of  these  lesions  while  con- 
tiguous areas  were  being  rayed  for  epithelioma.  Pusey  re- 
ports that  in  some  of  his  cases  so  treated  improvement  has 
remained  for  as  long  as  four  years. 

When  an  apparent  malignant  degeneration  has  occurred 
the  treatment  is  that  of  epithelioma  (q.  u). 


KERATO-ANGIOMA. 

Description. — This  affection,  first  described  by  Cottle 
and  more  fully  by  Mibelli,  occurs  usually  on  the  hands  and 
feet  of  young  persons,  the  subjects  of  chilblains,  and  con- 
sists of  warty  growths  that  are  developed  over  dilated 
vessels.  The  usual  situations  of  the  disorder  are  the  dorsal 
surfaces  of  the  fingers  and  toes,  but,  exceptionally,  other 
localities  may  be  invaded.  The  lesions  are  minute,  red  or 
violet  spots,  which  may  be  made  to  disappear  under 
pressure.  Among  them,  in  the  course  of  time,  are  to  be 
noted  larger  capillary  varices,  which  can  be  made  to  pale  by 
pressure,  but  from  which  the  blood  cannot  be  entirely 
emptied.  The  superimposed  horny  layer  becomes  thicker, 
but  retains  its  transparency,  showing  the  vascularity 
beneath,  and  the  lesions  have  otherwise  the  appearance  of 
an  ordinary  wart.  These  angiokeratomas  are  sometimes 
discrete  and  sometimes  arranged  in  clusters. 

Treatment. — The  treatment  is  by  electrolysis. 


POROKERATOSIS. 

Description. — This  rare  disorder  is  a  non-inflammatory 
hypertrophy  of  the  epithelial  structures  of  the  skin  that  be- 
gins as  warty  or  callous  spots  of  different  sizes  and  shapes. 
These  presently  become  depressed  in  the  centre,  while  slowly 
spreading  at  the  periphery,  until  there  results  a  serpiginous 
seam  or  "dike,"  enclosing  areas  of  varying  extent.  The  ri<  Igr 


204  HYPERTROPHIES 

or  seam  may  be  continuous  for  considerable  distances,  or  it 
may  be  interrupted  in  places,  and  also  sometimes  exhibits 
conical  elevations  along  the  crest.  The  enclosed  areas 
may  be  atrophic  and  hairless,  or  else  of  normal  appearance. 
The  surface  of  some  of  the  enclosed  spaces  is  at  times 
covered  with  scattered  horny  bodies.  The  usual  sites  of 
predilection  are  the  backs  of  the  hands  and  feet,  then  the 
rest  of  the  extremities — the  face,  neck,  and  scalp.  It  spreads 
with  extreme  slowness,  in  many  instances  remaining  in 
the  same  situation  for  years.  The  disorder  usually  begins 
between  the  second  and  eighth  years,  but  a  later  develop- 
ment at  twenty-six  has  been  observed. 

Porokeratosis  is  a  family  disease,  that  is,  it  appears  in 
parents  and  offspring,  brothers  and  sisters. 

Treatment. — Excision  of  the  lesions  has  been  practised 
with  satisfactory  results,  but  scarring  has  ensued;  on  the 
other  hand,  electrolytic  destruction  has  been  just  as  suc- 
cessful, besides,  as  would  be  expected,  producing  a  much 
better  cosmetic  effect.  The  re-rays  would  probably  serve 
still  better. 


CALLOSITAS. 

Description. — Callosities  are  thickenings  of  the  epidermis 
which  may  be  congenital,  but  are  usually  acquired  as  the 
result  of  local  irritation.  The  most  frequent  sites  for  cal- 
losities are  the  palms  and  soles.  The  skin  is  usually  thick- 
ened over  some  bony  prominence,  as  the  metacarpo- 
phalangeal  joints.  The  lesions  of  callositas  are  of  various 
sizes,  rounded  in  outline,  slightly  raised  above  the  general 
level,  yellowish  or  brownish  in  color,  and  hard  to  the  touch. 
The  entire  alteration  occurs  in  the  horny  layer  of  the 
epidermis. 

Callus  on  the  palms  is  usually  the  result  of  pressure 
sustained  in  the  occupation  of  the  affected  person ;  but  on 
the  soles,  while  there  are  a  number  of  factors  involved, 
such  as  ill-fitting  shoes,  etc.,  one  of  us  has  recently  called 


CALLOSITAS  205 

attention1  to  the  frequency  with  which  callus  in  this  situa- 
tion is  associated  with  malpositions  of  the  feet,  that  is,  weak- 
foot,  flatfoot,  or  anterior  metatarsalgia  (Morton's  foot). 

It  is  well  known  that  callus  and  warty  growths  are  not 
uncommon  concomitants  of  hyperidrosis,  and  in  many 
instances,  at  least,  the  hyperidrosis  is  the  first  symptom  of 
the  relaxed  condition  of  the  foot. 

Treatment. — In  the  cases  where  a  moderate  amount  of 
callous  epidermis  has  been  produced  by  the  occupation  of 
the  patient,  it  is  unnecessary  to  remove  it,  as  it  acts  as  a 
protection  to  the  tender  layers  beneath.  In  any  case,  to 
cure  the  condition,  it  will  be  necessary  to  remove  the  cause. 
In  a  considerable  number  of  cases  of  callus  of  the  soles 
there  is  no  doubt  that  the  malposition  of  the  feet,  as  stated 
above,  is  mainly  responsible,  and  certainly  it  is  a  safe  rule 
carefully  to  examine  them,  or  better  still,  to  refer  such 
patients  to  an  experienced  orthopedic  surgeon.  Dr. 
Nathaniel  Allison,2  of  St.  Louis,  to  whom  we  have  referred 
many  such  cases,  makes  the  following  statement:  "The 
method  of  treatment  that  I  have  used,  and  which  in  the 
above  series  of  cases  has  afforded  relief  in  each  instance, 
has  been  the  ordinary  methods  employed  for  the  treatment 
of  Morton's  metatarsalgia  or  for  weakened  or  collapsed 
longitudinal  arch.  The  employment  of  steel  plates  as 
supports,  I  have  found  not  to  be  suitable  to  every  case. 
The  method  of  support  supplied  has  been  a  small  convex 
felt  pad  placed  under  the  anterior  arch,  with  its  point  of 
greatest  convexity  at  or  near  the  centre  of  the  callosity,  or  a 
celluloid  or  steel  plate.  In  the  treatment  of  the  longi- 
tudinal arch,  it  was  found  that  a  slight  modification  of  the 
sole  of  the  shoe  was  sufficient  in  some  cases  to  relieve  the 
painful  symptoms,  whereas  others  have  required  a  strong 
steel  support.  These  various  methods,  coupled  with 
exercise  and  massage,  have  afforded  entire  relief  in  the 
majority  of  cases." 

1  Warty  Growths,  Callosities  and  Hyperidrosis,  and  their  Relation 
to  Malposition  of  the  Feet.     By  W.  A.  Hardaway  and  N.  Allison, 
Journal  of  Cutaneous  Diseases,  March,  1906. 

2  See  article  quoted  above. 


206  HYPERTROPHIES 

As  to  the  local  treatment  of  the  callus  itself,  the  best  and 
simplest  plan  is  to  remove  the  horny  layer  by  the  appli- 
cation of  a  salicylic  acid  plaster,  10  to  20  per  cent.,  or  by 
painting  on  a  solution  of  salicylic  acid  in  collodion: 

!$ — Acidi  salicylic! 3ss 

CoUodii .     5ss— M. 

S. — Paint  over  callus. 

If  the  callus  is  very  painful  it  may  be  first  poulticed  or 
soaked  in  oil,  or  a  5  per  cent,  salicylated  soap  plaster  may 
be  applied  to  it,  the  plaster  being  spread  on  thick  cotton 
cloth.  (See  p.  93.)  It  is  safer  to  avoid  the  applications 
of  liq.  potassae,  lactic  acid,  etc.,  usually  mentioned  in  the 
text-books. 

In  callosities  of  the  feet  complicated  with  hyperidrosis, 
Pusey  has  found  the  o>rays  very  satisfactory. 

CLAVUS. 

Description. — A  clavus  or  corn  is  a  circumscribed  thick- 
ening of  the  epidermis  which  grows  in  depth  as  well  as 
superficially.  Corns  are  most  often  found  where  pressure 
occurs  on  the  toes.  Corns  are  hard  or  soft,  according  to 
whether  they  are  in  a  situation  where  they  are  dry  or 
moist.  Hard  corns  occur  mostly  on  the  outer  side  of  the 
little  toe  and  upon  the  tops  of  the  toes,  while  soft  corns  are 
most  common  between  the  toes.  A  corn  may  become 
acutely  inflamed  and  suppurate,  leaving  a  painful  ulcer. 

Treatment. — In  the  treatment  of  corns  the  first  thing  is 
to  remove  all  injurious  pressure  from  ill-fitting  shoes.  The 
thickened  epidermis  should  then  be  removed,  after  soaking 
in  hot  water,  with  a  sharp  knife.  Another  way  to  effect 
the  removal  of  the  corn  is  to  apply  salicylic  acid,  either 
in  the  form  of  a  plaster  or  in  collodion,  1  drachm  to  1  oz. 
The  corn  should  then  be  neatly  strapped  with  rubber 
plaster,  or  a  felt  ring  may  be  worn  over  it.  The  soft  corn 
should  be  removed  as  above  recommended,  and  the  base 
touched  with  some  mild  caustic;  after  this  the  feet  should 


VERRUCA  207 

be  washed  every  day  with  soap  and  water,  and  bits  of 
absorbent  cotton  pushed  in  between  the  toes  to  keep  them 
apart. 

Stel wagon  thinks  well  of  lactic  acid.     Zeisler  removed 
sixty  soft  corns  from  one  foot  by  the  x-ray. 


CORNU  CUTANEUM. 

Description. — Cutaneous  horns  are  essentially  agglu- 
tinated warts  (Kaposi).  They  may  appear  in  any  region, 
but  are  commonest  about  the  face,  scalp,  and  penis.  They 
may  develop  from  sebaceous  cysts,  warts,  or  scars.  They 
vary  in  size  from  one  to  several  inches,  and  often  bear  a 
close  resemblance  to  the  same  outgrowth  in  animals. 
Sometimes  a  cancerous  degeneration  takes  place  at  the 
base  of  cutaneous  horns. 

Treatment. — After  the  excrescence  has  been  removed  by 
the  knife,  scissors,  or  by  electrolysis,  it  is  necessary  to 
cauterize  the  base  to  prevent  recurrence. 

Scholtz  secured  the  disappearance  of  a  cutaneous  horn 
with  one  moderate  irradiation.  Belot  had  a  good  result 
with  two  rayings  a  fortnight  apart,  using  10  H.  the  first 
time  and  only  3  the  next. 


VERRUCA. 

Description. — The  verruca,  or  wart,  has  been  divided 
into  several  clinical  varieties  depending  upon  its  form  or 
other  features:  Verruca  vulgaris,  verruca  digitata,  verruca 
plana,  verruca  filiformis,  verruca  acuminata,  etc.  Warts 
may  occur  singly  or  in  numbers;  they  may  be  discrete  or 
confluent;  and,  as  will  be  presently  noted,  they  may  have 
a  variety  of  shapes  and  sizes,  and  vary  considerably  in 
consistency  and  other  physical  characters.  Warts  are 
most  frequently  seen  on  the  hands,  face,  neck,  and  genital 
region. 


208  HYPERTROPHIES 

The  common  wart  is  too  well  known  to  need  description, 
but  from  the  point  of  view  of  treatment  the  physical 
features  of  several  of  the  less  common  varieties  of  wart 
may  be  briefly  mentioned. 

Verruca  Filiformis. — These  thread-like  or  filamentous 
offshoots  from  the  skin,  are  mostly  seen  on  the  necks  of 
elderly  persons.  The  term  acrochordon  applied  to  it  by 
some  writers  is  objectionable  inasmuch  as  it  is  also  given 
to  a  stage  of  the  fibromatous  process. 

Verruca  Senilis. — These  localized  hypertrophies  appear 
as  flat,  dry,  freckle-like  collections  of  scales,  occurring 
mostly  on  the  backs  of  the  hands  and  upper  part  of  the 
face.  They  may  also  be  found  on  the  trunk,  forearms,  and 
feet.  When  fully  developed  they  attain  considerable  height 
— perhaps  one-eighth  of  an  inch,  and  consist  of  blackish, 
cornified  scales,  which,  when  removed,  reveal  a  slightly 
bleeding  surface. 

The  patch  is  often  greasy  to  the  touch.  This  condition 
constitutes  the  seborrheic  wart  of  Unna  and  Pollitzer. 

This  affection  gains  considerably  in  importance  when 
we  remember  the  frequency  with  which  keratosis  senilis 
undergoes  malignant  transformation,  being  often  in  fact 
the  starting  point  for  epithelioma. 

Verruca  Plana  Juvenilis. — As  its  name  indicates,  this 
form  of  wart  occurs  in  young  people,  and  it  is  observed 
mostly  on  the  chin,  cheeks,  forehead,  and  backs  of  the 
hands.  In  size  they  vary  from  a  pin's  head  to  a  French 
pea;  are  usually  the  color  of  the  skin  or  somewhat  grayish, 
occasionally  reddish,  and  are  only  slightly  elevated.  In 
shape  they  are  round  or  polygonal  and  sometimes  strongly 
suggestive  of  lichen  planus.  Leredde  states  that  they  are 
auto-inoculable. 

Prognosis. — The  ordinary  wart  is  benign  in  character 
and,  as  is  well  known,  of  an  erratic  disposition.  The  so- 
called  seborrheic  wart  of  old  people  should  always  be  held 
under  suspicion.  The  verruca  plana  juvenilis  is  obstinate, 
but  usually  disappears  in  time.  Acuminate  warts  get  well 
under  proper  management. 


VERRUCA  209 

Treatment. — Colrat  claims  that  sulphate  of  magnesium 
given  for  some  time  in  doses  of  30  gr.,  three  times  a  day, 
for  adults,  will  cure  warts.  Among  other  internal  remedies 
may  be  mentioned  arsenic,  tincture  of  thuja,  nitromuriatic 
acid  and  lime-water.  Never  having  tried  these  drugs,  we 
have  no  experience  in  their  use. 

A  great  many  methods  for  the  local  treatment  of  warts 
have  been  advised.  The  best  local  treatment  is,  we  believe, 
by  electrolysis,  and  it  is  to  be  remarked  that  the  electro- 
lyzation  need  not  go  on  to  complete  destruction,  but  that 
often  merely  transfixing  the  wart  with  the  needle  is  suf- 
ficient. In  young  children,  who  will  not  submit  to  the  slight 
pain  of  this  operation,  painting  the  wart  with  a  saturated 
solution  of  salicylic  acid  in  alcohol  will  generally  suffice. 
The  salicylic  acid  in  traumaticine  or  collodion  (1$ — Acid 
salicylic,  3ss;ext.  cannabis  indicse,  gr.  v;  collodii,  5j — M.), 
or  in  the  form  of  Beiersdorf 's  plaster  is  still  more  effectual. 
Whitfield  mentions  resorcin  10  per  cent. 'in  plaster  or 
collodion.  The  various  caustic  applications,  such  as  the 
acid  nitrate  of  mercury,  caustic  potash,  or  nitric,  chromic 
or  trichloracetic  acid,  may  also  be  employed  for  destructive 
purposes,  but  the  methods  already  mentioned  are  safer  and 
better. 

In  case,  however,  it  is  determined  to  use  a  caustic,  and 
the  trichloracetic  acid  is  the  only  one  we  should  recom- 
mend, the  skin  surrounding  the  wart  should  be  thoroughly 
protected  from  injury  by  a  ring  of  wax,  and  the  remedy 
cautiously  applied  by  means  of  an  appropriate  applicator. 

The  filiform  wart  may  be  removed  by  electrolysis  or  by 
the  application  of  the  minutest  quantity  of  trichloracetic 
acid,  taking  care  to  shield  the  contiguous  skin. 

The  treatment  of  the  flat  wart  (verruca  plana  juvenilis) 
is  by  no  means  easy.  Electrolysis  does  not  act  as  well  as  in 
the  common  wart,  but  it  may  be  tried.  The  needle,  a  very 
fine  one,  should  be  introduced  no  deeper  than  the  level, 
if  so  deep,  of  the  skin,  and  then  reintroduced  at  several 
different  points.  A  very  mild  current  should  be  employed. 
Trichloracetic  acid  is  of  some  value  if  used  properly.  A 
14 


210  HYPERTROPHIES 

good  plan  is  to  wrap  about  the  point  of  a  very  fine  wooden 
tooth-pick  the  merest  fragment  of  absorbent  cotton,  so  as 
to  avoid  taking  up  too  much  of  the  acid,  and  with  this 
barely  to  moisten  the  warts,  seeing  also  that  the  applica- 
tion does  not  trespass  on  the  unaffected  skin.  We  may 
remark,  in  passing,  that  either  the  deep  or  the  superficial 
action  of  trichloracetic  acid  may  be  secured  by  the  manner 
of  its  use.  If  a  light  effect  is  desired,  the  acid  should  be 
merely  dropped  on  the  part  to  be  treated ;  if  a  more  or  less 
profound  effect  is  desired,  then  the  acid  is  more  or  less 
vigorously  rubbed  in.  Stelwagon  has  had  good  results 
from  a  5  or  10  per  cent,  sulphur  or  calomel  ointment,  and 
Davis,  from  a  saturated  solution  of  boric  acid  with  from  2 
to  10  or  15  gr.  of  resorcin  to  1  oz.,  while  both  he  and  Hyde 
speak  well  of  the  local  use  of  Vleminckx's  solution. 

The  x-ray  has  been  used  with  success  by  Varney,  Belot, 
Scholtz,  and  Holzknecht.  The  latter  gives  8  H.  at  a  single 
sitting.  In  a  Case  of  abundant  warts  on  the  hands,  he  pro- 
tected the  sound  skin  with  mercurial  plaster,  in  which 
apertures  were  cut  corresponding  to  the  warts.  The  nails 
were  covered  with  lead.  Kothe,  of  Bonn,  achieved  a  cure 
by  injecting  a  1  per  cent,  solution  of  eosin  into  the  warts 
before  raying. 

Bulkley  advises  sparking  with  the  high-frequency  cur- 
rent, using  a  glass  or  carbon-pointed  electrode. 

Acuminate  warts,  or  vegetations,  should  be  washed  with 
some  disinfecting  lotion,  such  as  a  solution  of  permanganate 
of  potassium  or  dilute  liquor  soda1  chlorate,  then  thoroughly 
dried,  and  afterward  dusted  with  boric  acid,  resorcin,  calo- 
mel, or  oxide  of  zinc  and  lycopodium  in  equal  parts.  In 
some  cases  the  galvanocautery  offers  the  speediest  and  best 
method  of  treatment. 

Verruca  Senilis.    (See  Keratosis  Senilis.) 

For  papillary  growths  on  the  sole  the  usual  treatment  by 
salicylic  acid,  caustics,  curettage,  etc.,  may  be  tried ;  or  Fitz's 
method  may  be  followed,  which  consists  of  the  applica- 
tion, daily  or  twice  a  day,  of  a  10  per  cent,  chrysarobin 
solution  in  traumaticine  or  ether.  In  this  condition,  as  in 


N&VUS  PIGMENTOSUS  211 

callus,  we  should,  by  all  means,  advise  that  the  anatomical 
condition  of  the  foot  be  ascertained.  We  have  seen  intract- 
able conditions  of  this  sort  cured  by  treatment  directed  to 
the  collapsed  arch. 

ADDITIONAL  PRESCRIPTION'S. 

1$  —  Glycerin!       ..........      3jss 

Acidi  acetici  diluti  ........ 


Sulphuris  przrcip  .....      ....      3j  —  M. 

S.  —  For  small,  multiple  warts.  Morris. 

1^  —  Potass,  chloratis      ........  gr.  xxiv 

Sulphuris  prjrcip  .........  gr.  xlviij 

Resorcini      ..........  gr.  xvj 

Vaselini  ...........  5j  —  M. 

S.  —  For  senile  warts.  Sabouraud. 


N^IVUS  PIGMENTOSUS. 

Description. — A  pigmented  naevus,  or  mole,  is  a  deposit 
of  pigment  in  the  skin.  A  mole  may  consist  of  a  circum- 
scribed hyperpigmentation  only,  or  alterations  in  other 
elements  of  the  skin  may  be  present,  constituting  naevus 
verrucosus,  when  the  surface  is  rough  and  warty,  or  naevus 
pilosus,  when  there  are  hairs  growing  from  the  mole. 
When  a  mole  is  loose,  flabby,  and  contains  fatty  tissue, 
it  is  spoken  of  as  naevus  lipomatodes. 

Pigmented  naevi  are  most  common  on  the  face,  neck, 
and  back.  A  number  of  naevi  are  sometimes  arranged  in  a 
line  or  band;  this  is  found  only  upon  one  side  of  the  body, 
and  has,  therefore,  been  called  naevus  unius  lateris. 

Moles  are  always  congenital  in  origin,  although  they  may 
not  become  apparent  until  later  life. 

One  of  the  most  important  facts  connected  with  moles  is 
that  late  in  life,  if  irritated,  they  not  uncommonly  form  the 
starting  point  for  malignant  growths. 

Treatment. — Electrolysis  is  the  best  method  of  removing 
moles  when  small.  Since  moles  are  removed  mainly  for 
cosmetic  reasons,  it  is  important  that  the  operator  should 


212  HYPERTROPHIES 

not  produce  more  disfigurement  than  the  growth  itself 
occasions.  Consequently,  the  electrolysis  should  be  done 
little  by  little,  and  with  an  interval  of  some  days  between 
each  operation,  in  order  to  take  stock  of  the  result,  as  it 
were.  We  usually  employ  a  fine  sewing  needle,  and 
endeavor  to  pass  it  very  superficially  through  the  growth 
in  the  beginning.  Later  on,  after  the  effect  of  the  operation 
has  worn  away,  little  irregularities  can  be  smoothed  down 
at  one  or  more  sittings.  Hairs,  when  present,  should  first 
be  removed  by  the  same  agent.  Larger  growths  may  be 
dealt  with  by  caustics  or  the  galvanocautery.  Hearn 
shaves  off  the  superficial  layer  of  simple,  flat  pigmentary 
nsevi,  as  in  making  a  Thiersch  graft.  Prominent,  deeply 
pigmented  moles  are  best  and  most  safely  dealt  with  when 
excised.  When  the  growth  is  irritated,  no  other  method 
should  be  considered. 

Pusey  obtained  a  most  gratifying  result  by  the  oxray  in 
a  disfiguring  case,  situated  on  the  forehead.  Hairs  sprung 
from  a  rough,  pigmented  surface.  The  cure  left  the  skin 
smooth,  only  a  little  darker  than  normal. 

Trimbell  and  Dade  destroy  the  growth,  a  part  at  a  time, 
by  rapid  freezing  with  liquid  air.  Pusey  does  the  same 
thing  with  solid  carbon  dioxide. 


ICHTHYOSIS. 

Description. — This  affection,  popularly  known  as  fish-skin 
disease,  is  apparently  dependent  upon  the  transmission  of 
an  hereditary  tendency,  and  appears  first  in  early  childhood. 
It  is  characterized  by  general  scaliness  and  unusual  dryness 
of  the  surface,  or  the  development  of  plates  separated  by 
fissures. 

The  milder  grade  affects  the  surface  generally,  but  is 
most  developed  on  the  extensor  aspects  of  the  limbs.  In 
many  cases  there  is  present  simply  an  unusual  dryness  and 
roughness  of  the  skin.  Associated  with  this  thickened  and 
scaly  state  of  the  epidermis,  there  is  always  present  more  or 


ICHTHYOSIS  213 

less  of  a  papular  eruption  due  to  accumulation  of  horny 
cells  in  the  hair  follicles,  keratosis  pilaris. 

In  a  severer  grade  of  ichthyosis  the  skin  is  rough,  thick- 
ened, fissured,  and  scaly.  The  plates  of  skin  are  usually 
diamond-shaped,  bearing  a  close  resemblance  to  the  mark- 
ings observed  upon  the  hide  of  the  alligator;  but  the 
physical  characters  of  the  scales  will  differ  somewhat 
according  to  the  locality,  etc.  The  scaling  sometimes 
occurs  in  thin,  papery  flakes,  or  it  may  be  thick  and  horny. 

The  thin  portions  of  the  skin,  face,  palms,  scalp,  soles, 
and  flexor  surfaces  generally  are  but  little  affected,  but  the 
hair  is  apt  to  be  harsh  and  lustreless,  and  the  nails,  rough, 
pitted,  and  easily  fractured.  There  is  almost  complete 
absence  of  perspiration,  and  the  sebaceous  secretion  is 
deficient  and  altered.  Itching  is  sometimes  present  in  a 
mild  degree,  and  the  deep  cracks  in  the  skin  may  occasion- 
ally be  very  painful.  Owing  to  the  increased  activity  of  the 
glands  in  summer,  and  the  consequent  softening  and 
shedding  of  the  epidermal  accumulations,  ichthyotic 
patients  improve  greatly  at  this  season,  and  the  lighter 
forms  of  the  disorder  may  even  entirely  disappear.  The 
general  health  is  not  appreciably  affected. 

The  term  ichthyosis  hystrix  may  be  properly  applied  to 
cases  in  which  the  scales  show  a  horny  excrescence.  Most 
of  the  cases  described  by  this  title  are  not  ichthyosis  at  all. 
Many  of  them  are  probably  instances  of  nsevus  unius  lateris. 
So-called  congenital  ichthyosis,  designated  in  extreme  grades 
as  "harlequin  fetus"  is  really  an  independent  condition, 
better  called  hyperkeratosis  congenita. 

Prognosis. — Ichthyosis  is  an  incurable  disorder,  but  by 
persistently  bathing  and  anointing  the  skin  the  patient 
may  be  kept  tolerably  comfortable.  Temporary  disap- 
pearance of  the  ichthyosis  has  been  sometimes  noted  after 
severe  illness;  and  Hebra  reports  two  permanent  cures,  in 
one  case  after  an  attack  of  measles,  and  in  another  following 
smallpox.  All  but  the  mildest  case  of  so-called  congenital 
ichthyosis  are  either  stillborn  or  perish  within  the  first  few 
days  of  life. 


214  HYPERTROPHIES 

Treatment. — Within  the  last  few  years  we  have  been  in 
the  habit  of  administering  two  or  three  of  Garrod's  sulphur 
tablets  a  day  in  some  mild  cases  of  ichthyosis  or  xerosis, 
and  it  has  seemed  to  us  that  the  result  was  good.  We 
should  mention,  however,  that  there  was  carried  on  a 
simultaneous  local  treatment.  David  Walsh  has  pre- 
scribed with  benefit  a  tablet  containing  5  gr.  thyroid  extract 
and  y1^  gr.  nitrate  of  pilocarpine ;  cod-liver  oil  is  sometimes 
of  service.  In  mild  cases  the  free  use  of  simple  warm  baths, 
followed  by  inunction  of  glycerin  or  lanolin  diluted  with 
cold  cream,  will  keep  the  skin  tolerably  smooth  and  pliant. 
Vapor  baths  are  also  helpful.  In  cases  of  greater  severity 
it  is  advisable  to  render  the  baths  alkaline  by  the  addition  of 
8  to  10  oz.  of  carbonate  of  soda.  Duhring  and  Stelwagon 
recommend  that  some  mild  ointment  be  first  rubbed  in  and 
allowed  to  remain  on  a  few  hours,  and  then  followed  with  a 
hot  bath  and  green  soap  washing,  which  in  turn  is  to  be 
rinsed  off  with  simple  warm  or  hot  water,  and  then  again 
the  surfaces  are  to  be  anointed  with  the  salve.  The  follow- 
ing preparations  are  recommended : 

1^ — Adipis  benzoati 3j 

Glycerin! tr[xl 

Vaselini 5ss — M 

S. — Apply  after  bathing. 

1$ — Potassii  iodidi 9j 

Glycerini 5j 

Adipis  benzoati, 

Olei  bubuli aa     §ss — M. 

S. — Apply  once  daily. 

This  latter  preparation  is  highly  commended  by  various 
authorities.  Naphthol  in  5  per  cent,  ointment,  together 
with  the  use  of  naphthol  soap,  is  regarded  favorably  by 
Kaposi.  Andeer  has  used  a  3  per  cent,  resorcin  salve  with 
asserted  success.  Sulphur  of  the  strength  of  1  drachm 
to  1  oz.  of  lard  or  vaselin  has  recently  been  brought 
forward.  It  is  also  recommended  to  impregnate  the  gar- 
ments with  its  fumes  every  few  days.  A  scruple  of  salicylic 
acid  to  2  drachms  of  oil  of  sweet  almonds  and  (J  drachms  of 
lanolin  is  also  valuable  in  conjunction  with  warm  alka- 


(EDEMA  NEONATORUM  215 

line  baths.  Walker  recommends  a  5  to  10  per  cent, 
ichthyol  ointment.  Duncan  observed  improvement  in  one 
case  with  the  o>ray. 

SCLEREMA  NEONATORUM. 

Description. — The  disorder  may  be  present  at  birth,  but 
in  this  case  the  children  are  usually  stillborn.  As  a  rule, 
sclerema  develops  in  the  first  few  days  of  life.  The  skin  of 
the  lower  extremities  is  first  affected,  and  later  successive 
portions  of  the  integument  until  the  whole  surface  is 
involved.  At  times  the  induration  begins  in  the  cheeks  and 
spreads  downward.  In  the  beginning  the  skin  is  of  a 
waxy  appearance,  and  feels  thick  when  pinched  up;  later 
it  has  a  livid  hue,  becomes  adherent,  and  can  no  longer  be 
rolled  between  the  fingers.  After  the  disorder  has  become 
fully  established,  the  body  is  rigid,  with  only  such  move- 
ment as  arises  from  the  shallow  breathing,  the  joints  are 
fixed,  the  child  is  unable  to  nurse,  and  the  whole  body  is 
so  stiff  that  it  can  be  held  out  horizontally  by  the  legs. 
The  respirations  are  slow  and  superficial  and  the  pulse 
falls  to  sixty  or  below.  The  temperature  is  also  subnormal, 
and  in  a  few  days  life  is  extinguished. 

Treatment. — The  treatment  should  be  directed  to  bring- 
ing the  temperature  up  to  the  normal,  and  to  this  end  the 
child  should  be  wrapped  in  cotton,  or,  if  practicable,  put 
in  an  incubator.  Nourishment  and  stimulation  should  be 
administered  by  the  rectum,  or  by  feeding  with  a  catheter. 
Money  reports  two  cases  of  recovery  under  the  use  of  inunc- 
tions with  mercurial  ointment,  and  Garrod  has  had  a 
similar  experience. 

CEDEMA  NEONATORUM. 

Description. — This  affection  begins  within  the  first  three 
days  of  life.  The  edema  spreads  from  the  lower  limbs 
upward,  affecting  the  hands  and  genitals.  The  skin  is 


216  HYPERTROPHIES 

pale  or  livid  and  pits  upon  pressure.  The  child  may  recover 
from  this  condition,  but  in  other  cases  the  edema  may 
become  general,  the  skin  red  or  darkish  yellow  and  very 
hard  to  the  touch,  respiration  becomes  difficult,  the  pulse 
weak,  and  the  child  succumbs  to  some  pulmonary,  intes- 
tinal or  cerebral  complication. 

Treatment. — The  treatment  consists  in  raising  the  body 
temperature  by  artificial  means,  frictions  from  below 
upward,  and  proper  feeding. 


SCLERO  DERMA. 

Description. — Clinically,  this  affection  is  characterized  by 
a  hardening  or  rigidity  of  the  skin.  In  the  diffuse  form  a 
considerable  portion,  or  even  the  entire  surface  of  the 
body,  may  be  involved.  It  may  make  its  appearance  in 
any  region,  but,  nevertheless,  has  a  decided  preference  for 
the  upper  portion  of  the  body.  It  has  a  tendency  to  spread 
over  extensive  areas  and  is  usually  symmetrical.  The 
attack  may  be  preceded  by  pain  in  the  joints,  a  chill, 
edema,  or  abnormal  sensations  in  the  part,  but  frequently 
it  comes  on  unheralded  and  insidiously,  and  the  patient 
only  becomes  aware  of  the  change  when  the  induration  is 
already  marked,  and  the  pliability  of  the  integument 
destroyed  or,  at  least,  seriously  impaired.  When  fully 
developed,  the  skin  is  tense,  infiltrated,  hard,  and  to  the 
touch  gives  the  impression  of  a  frozen  cadaver,  without  the 
feeling  of  coldness.  It  does  not  pit  on  pressure,  and  cannot 
be  pinched  up  into  folds,  or  moved  over  the  deeper  struc- 
tures, to  which  it  seems  firmly  adherent. 

The  infiltration  merges  gradually  into  the  surrounding 
tissue  and  its  boundary  is  consequently  Hi-defined.  In 
color  it  may  be  white  or  waxy,  but  is,  as  a  rule,  more  or 
less  pigmented.  The  temperature  may  be  normal  or  even 
slightly  increased,  but  usually  is  somewhat  (1°  to  2°)  lower 
than  that  of  the  healthy  skin.  The  rigidity  of  the 
integument  seriously  limits  or  suspends  movement  of  the 


SCLERODERMA  217 

diseased  surface.  The  features  are  rigid,  immobile,  and 
expressionless,  as  though  cut  in  stone.  The  lips  are  con- 
tracted, the  mouth  narrowed,  and  the  eyelids  can  hardly 
be  closed.  Attacking  the  chest  or  abdomen,  respiration  is 
interfered  with,  and  the  mammae  flattened.  The  extremi- 
ties become  fixed  in  a  more  or  less  flexed  position,  and  the 
joints  pseudo-anchylosed,  their  immobility  being  due  not 
to  bony  union,  but  to  contraction  of  their  integumentary 
covering. 

The  mucous  membranes  are  by  no  means  exempt. 

Having,  after  the  lapse  of  weeks,  months,  or  years, 
reached  its  acme,  the  affection  may  remain  quiescent  for  a 
variable  length  of  time,  or  it  may  gradually  undergo  spon- 
taneous involution.  Frequently,  however,  the  sclerotic 
skin  becomes  atrophic.  The  contraction  and  constriction 
produce  atrophy  of  the  subcutaneous  fat,  fascia,  and 
muscles,  and  the  integument  becomes  firmly  adherent  to 
the  bone,  so  that,  literally  speaking,  the  part  seems  made 
up  solely  of  skin  and  bone.  According  to  Crocker  and 
others,  atrophic  changes  occur  only  in  those  cases  in  which 
the  disorder  begins  as  a  hard  edema,  whereas  in  the  fibrotic 
or  infiltrated  form  of  the  disease  the  patches  remain 
unchanged. 

The  general  health  is  not  affected  in  the  earlier  stages 
and  may  remain  good  for  years,  but  eventually,  in  the  bad 
cases,  the  patient  becomes  depressed,  emaciated,  and  a 
state  of  marasmus  supervenes,  which  sooner  or  later  termi- 
nates in  death. 

Etiology. — The  etiology  of  scleroderma  is  obscure.  It  is 
more  than  probable  that  the  tegumentary  changes  are  due 
to  disorder  of  the  nervous  system,  to  use  a  somewhat  vague 
expression.  Among  the  immediate  exciting  or  predisposing 
factors  that  have  seemed  to  play  a  part  in  the  production  of 
scleroderma,  may  be  mentioned  exposure  to  extremes  of 
temperature,  rheumatism,  erysipelas,  mental  emotion,  etc., 
while  on  the  other  hand,  cases  have  developed  without  any 
appreciable  exciting  influence.  The  disease  is  commoner 
in  women  than  in  men,  and  although  met  with  at  the  ex- 


218  HYPERTROPHIES 

tremes  of  life,  is  more  prevalent  in  persons  of  early  adult 
or  middle  life. 

Prognosis. — On  the  whole  the  prognosis  may  be  declared 
to  be  uncertain.  Some  cases  recover  spontaneously  in 
months  or  years,  while  again  the  disease  may  persist 
indefinitely,  or  end  in  marasmus  and  death.  The  cases 
that  begin  with  edema  pursue  a  more  unfavorable  course 
than  the  infiltrated  form. 

Treatment. — The  treatment  is  unsatisfactory.  Particular 
attention  should  be  paid  to  improving  the  general  nutrition 
of  the  patient,  and  to  diet  and  general  hygienic  measures. 
Phillipson  reports  two  cases  of  generalized  scleroderma  in 
which  a  cure  was  effected  by  the  administration  of  salol 
in  doses  of  from  1  to  4  gm.  daily.  This  is  in  keeping  with 
Graham's  suggestion  of  the  value  of  antirheumatic  reme- 
dies in  the  disease.  Very  naturally,  thyroid  extract,  or 
thyroidin,  might  be  tried  in  suitable  cases,  but  it  would 
seem  that  Osier's  personal  experience  is  not  in  its  favor, 
although  he  states  that  it  may  be  tried  without  harm  to  the 
patient.  H.  Hebra  has  recommended  deep  injections  of 
thiosinamin  (10  minims  of  a  15  per  cent,  alcoholic  solu- 
tion) every  second  day,  and  arsenious  acid  has  also  been 
administered  hypodermically. 

Locally,  electricity  and  stimulation  by  shampooing  and 
massage  have  been  recommended.  With  the  latter  we 
may  use  lanolin  containing  1  per  cent,  of  salicylic  acid. 


MORPHEA  (CIRCUMSCRIBED  SCLERODERMA). 

Description. — This  peculiar  affection  is  sometimes  called 
the  keloid  of  Addison.  In  the  more  usual  form  of  the 
disease  the  lesions  are  present  in  the  skin  as  variously 
sized,  round,  oval  or  irregular  patches  having  well-defined 
margins  surrounded  by  a  lilac  border  made  up  of  minute 
capillaries.  The  appearance  of  the  morphea  patch  is  so 
characteristic  that  once  seen  it  is  not  readily  forgotten. 
The  comparison  of  the  general  appearance  of  the  lesion  to 


MORPHEA  219 

a  plaque  of  old  ivory  set  in  the  skin  is  very  happy,  although 
at  times  the  color  is  pinkish,  or  perhaps  of  various  shades 
of  brown,  yellow,  purple,  or  black.  The  surface  of  a  patch 
is  generally  smooth  or  slightly  wrinkled,  and  in  the  begin- 
ning may  be  somewhat  elevated  above  the  surface,  level 
with  it,  or  later  a  little  sunken.  The  disease  is,  as  a  rule, 
symmetrical.  A  certain  amount  of  pain  is  present  in  some 
cases,  but  often  this  is  absent.  Slight  or  even  marked 
itching  may  be  a  symptom. 

Sometimes  there  is  only  one  patch  to  be  noted,  but  in 
other  cases  there  may  be  a  number  present.  After  a  vari- 
able duration — months  or  years — the  disease  may  undergo 
involution,  leaving  the  integument  perfectly  normal,  while 
in  other  instances  contraction  and  deformity  with  wasting 
and  general  atrophy,  especially  of  the  limbs,  may  result. 
Morphea  may  assume  other  features  than  those  just  men- 
tioned. The  disease  may  occur  in  bands,  streaks,  and 
atrophic  pits. 

Etiology. — Females  are  more  often  affected  than  males. 
All  save  one  of  our  patients  have  been  females,  the  youngest 
being  fourteen  years  of  age,  and  the  oldest  thirty-six.  It  is 
said  that  the  band  form  is  more  frequent  in  children. 
The  condition  of  the  general  health  seems  to  have  no  definite 
relation  to  the  causation  of  the  disease.  Various  kinds  and 
degrees  of  local  irritation  would  seem  to  act  as  exciting 
causes  in  some  cases.  By  most  writers  morphea  regarded 
as  a  circumscribed  form  of  scleroderma,  a  relationship  that 
is  borne  out  by  certain  clinical  and  anatomical  circum- 
stances. 

Prognosis. — A  guarded  opinion  as  to  the  probable  course 
and  termination  of  morphea  is  demanded,  although,  in  a 
general  way,  it  may  be  stated  that  after  some  years  then-  is 
a  tendency  to  the  disappearance  of  the  disease,  and  mostly 
without  local  detriment. 

Treatment. — Among  the  internal  remedies  that  some- 
times seem  of  value  in  this  disease  may  be  mentioned 
thyroid  extract  or  thyroidin,  iodide  of  potassium,  salol,  and 
the  salicylates. 


220  HYPERTROPHIES 

Naturally,  the  x-ray  has  been  used  in  morphea.  Belot, 
who  has  had  some  experience  in  the  matter,  says  that  it  is 
well  known  that  certain  cases  of  morphea  get  well  spontane- 
ously, and  that  we  should,  therefore,  be  cautious  in  attribu- 
ting any  amelioration  to  the  use  of  the  ar-rays  alone,  and 
he  agrees  with  Pfahler  that  the  results  of  this  treatment 
are  but  small  in  comparison  with  the  time  and  energy 
expended.  Brocq  employs  electrolysis,  making  use  of  a 
current  of  from  ^  to  10  ma.  according  to  the  amount  of 
infiltration  and  the  endurance  of  the  patient.  The  opera- 
tion is  practically  the  same  as  that  for  the  destruction  of 
the  hair  papilla  (q.  v.}. 

Mercurial  plaster  is  used  in  conjunction  with  this 
treatment.  Thiosinamin  injections  have  been  used  as  in 
keloid. 

Although  Brocq  reports  favorably  on  the  use  of  electroly- 
sis in  morphea,  we  believe  that  as  a  method  of  treatment 
it  will  find  no  wide  acceptance,  being  both  tedious  and 
painful. 

Leredde  says  that  the  high-frequency  current  is  to  be 
recommended  in  certain  cases.  Galvanism  and  massage 
may  be  tried,  as  well  as  general  and  local  static  electricity. 


ELEPHANTIASIS. 

Description. — Elephantiasis,  sometimes  called  elephanti- 
asis arabum,  lepra  arabum  and  Barbadoes  leg,  has  nothing 
in  common  with  leprosy.  The  disease  is  characterized 
by  repeated  attacks  of  inflammation,  by  hypertrophy  of  the 
skin  and  subcutaneous  tissue,  and,  as  a  result,  by  enormous 
enlargement  and  deformity  of  the  parts  affected.  The 
disorder  is  both  endemic  and  sporadic,  and,  while  differing 
symptomatically  in  some  respects  according  to  the  exciting 
cause,  the  result  is  in  all  cases  the  same. 

According  to  Crocker,  nothing  corresponding  to  the 
elephantoid  fever  is  observed  in  England,  but  the  febrile 
attacks  agree  in  extent  and  severity  with  the  attacks  of 
erysipelas.  In  a  number  of  cases  that  we  have  seen  the 


ELEPHANTIASIS  221 

same  state  of  affairs  was  noted,  or  else  the  enlargement  was 
progressive,  but  was  unaccompanied  by  any  fever  at  all. 

The  regions  most  commonly  affected  are  the  legs, 
usually  one  only,  but  in  tropical  countries  often  both,  the 
male  and  female  external  genital  organs,  the  arms,  fore- 
arms, hands,  scalp,  ears,  lips,  cheeks,  and  tongue.  As 
commonly  seen  on  the  leg,  the  clinical  picture  is  striking. 
The  most  notable  feature  is,  of  course,  the  enormous  size 
of  the  member,  hence  the  name  of  "elephant  leg."  The 
limb  is  misshapen  and  unwieldy,  and  the  normal  contours 
are  effaced.  The  condition  of  the  skin  varies  in  different 
cases;  sometimes  it  is  dry  and  tuberculated,  sometimes 
smooth  and  parchment-like,  and  in  other  cases  eczematous, 
ichthyotic,  warty,  or  deeply  fissured.  The  lymphatics  often 
become  varicose,  and  a  veritable  lymphorrhea  is  not  in- 
frequent. 

Subjective  sensations  are  not  especially  marked.  When 
eczema  exists  as  a  complication,  there  is  considerable  itch- 
ing, and  during  the  inflammatory  exacerbations  the  local 
suffering  may  be  severe.  Pain  may  also  be  present  if  the 
case  is  complicated  with  deep  fissures  and  varicose  ulcers. 
The  great  weight  of  the  affected  parts,  and  the  inconveni- 
ence arising  therefrom,  cause  the  most  annoyance. 

A  condition  called  lymph  scrotum,  varix  lymphaticus,  or 
nevoid  elephantiasis  has  been  described  as  occurring  in 
China,  in  which,  according  to  Manson,  there  are  present 
on  the  surface  of  the  scrotum  vesicles  and  enlarged  lym- 
phatics that  when  pricked  or  spontaneously  ruptured 
discharge  a  coagulable  fluid.  A  very  remarkable  state 
called  "  acromegalia,"  which,  however,  is  only  objectively 
allied  to  elephantiasis,  has  received  attention  from  various 
writers.  The  disease  is  an  hypertrophy  of  the  head  and 
extremities,  occurring  in  middle  life,  and  presenting 
symptoms  that  are  mainly  connected  with  the  nervous 
system.  According  to  Shepherd  an  enlargement  of  the 
pituitary  body  has  been  found  postmortem,  and  the  thyroid 
gland  is  atrophied  or  diseased. 

Elephantiasis  is  due  to  the  occlusion  of  lymphatics,  the 


222  HYPERTROPHIES 

result  of  inflammation,  or  arising  from  mechanical  causes. 
Tropical  elephantiasis  is  now  known  to  be  caused  by  the 
presence  of  the  Filaria  sanguinis  hominis,  the  mosquito 
being  the  intermediary  host. 

As  seen  in  this  country,  the  disease  may  be  brought 
about  in  a  variety  of  different  ways,  such  as,  for  example, 
by  repeated  attacks  of  erysipelas,  chronic  eczema  of  the 
lower  extremities,  etc. 

Cases  have  been  reported  in  which  there  was  an  appar- 
ently hereditary  influence.  One  of  the  most  remarkable 
cases  that  ever  came  under  our  observation  was  in  the 
person  of  a  lady  who  had  been  confined  to  her  chair  for 
many  years  by  rheumatism.  In  this  instance  both  legs 
were  enormously  enlarged. 

Prognosis. — It  is  said  that  in  the  early  stages  of  the 
disease  spontaneous  recovery  may  take  place,  but,  as 
ordinarily  seen,  elephantiasis  is  a  persistent  affection, 
although  not  necessarily  a  fatal  disorder. 

Treatment. — In  tropical  cases,  change  of  climate  is  the 
most  reasonable  prescription.  Drugs  are  not  especially 
efficient,  except  in  the  acute  stage  to  relieve  the  inflamma- 
tory symptoms  and  the  attendant  pain.  Rest  and  an 
elevated  position  of  the  parts  are  to  be  recommended. 
Elephantiasis  of  the  genitals  may  be  advantageously 
treated  by  amputation.  Ligature  of  the  main  artery  of  the 
limb  is  generally  only  palliative,  but  a  sufficiently  large 
number  of  satisfactory  results  have  been  reported  to  war- 
rant the  operation  in  severe  cases.  Morton  secured  a  good 
degree  of  amelioration  by  excision  of  a  portion  of  the 
sciatic  nerve  in  a  case  where  ligature  of  the  iliac  artery  had 
been  futile.  The  application  of  blisters  and  the  inunction 
of  iodine  and  mercurial  salves  have  been  advocated.  Mon- 
corvo  and  Silva  Aranjo  have  used  a  galvanic  current  of  40 
to  GO  Trouve"  elements  with  remarkable  success.  The 
applications  lasted  from  five  to  thirty  minutes,  the  positive 
electrode  being  placed  on  the  healthy  parts  and  the  negative 
moved  about  over  the  affected  region.  In  1879  one  of  us1 

1  Harclaway,  St.  Louis  Courier  of  Mrdicinc,  May,  1879. 


MYX EDEMA  223 

suggested  the  use  of  the  Martin  bandage,  although  it  had 
probably  already  been  used  by  others.  The  leg  should 
first  be  powdered  with  starch,  to  which  may  be  added  a 
small  quantity  of  salicylic  acid,  and  over  this  a  thin  stock- 
ing should  be  drawn,  as  the  rubber  coming  directly  into 
contact  with  the  skin  is  too  irritating.  When  the  patient  is 
confined  to  the  house,  the  limb  may  be  kept  elevated. 
We  have  seen  good  results  from  the  application  of  Squire's 
glycerole  of  the  subacetate  of  lead,  used  in  the  same 
strength  and  put  on  in  the  same  way  as  for  eczema  rubrum 
of  the  leg.  The  compound  salicylated-soap  plaster  spread 
on  strips,  and  evenly  bound  on  the  leg,  has  proved  useful 
in  our  practice.  Ulcers  may  be  dressed  with  xeroform. 
These  latter  procedures  have  reference,  of  course,  to  the 
treatment  of  the  eczema,  etc.,  that  often  accompany  the 
elephantiasis,  but  in  a  case  in  which  one  of  us  used  the 
glycerole  of  lead  dressing,  an  exceedingly  profuse,  watery 
discharge  came  from  the  legs,  and  there  ensued  a  remark- 
able diminution  in  their  size. 


MYXEDEMA. 

Description. — This  is  a  general  disorder  of  nutrition,  due 
to  atrophy  or  loss  of  function  of  the  thyroid  gland.  There 
are  two  forms:  the  congenital,  also  known  as  sporadic 
cretinism,  and  the  acquired. 

The  latter  is  more  common  in  women  than  in  men,  and 
is  more  apt  to  appear  after  middle  life.  Several  members 
of  a  family  may  be  affected,  and  maternal  transmission  of 
the  disease  has  been  observed.  The  facial  expression  is 
characteristic:  the  features  are  broad,  coarse,  and  appar- 
ently puffy;  the  lower  lip  is  thick  and  everted,  and  the  lines 
of  the  face  obliterated.  Moles  and  warty  growths  are 
common.  The  general  integument,  as  well  as  the  mucous 
membranes,  are  almost  equally  affected;  the  hands  and 
feet,  for  example,  being  swollen  and  clumsy.  There  is 
a  fairly  general  alopecia,  and  the  nails  are  stunted  and 


224  HYPERTROPHIES 

brittle.  Tumefaction  of  the  skin  and  subcutaneous  tissue 
is  marked  in  the  supraclavicular  regions.  Speech  is  slow 
and  the  mental  faculties  are  greatly  dulled.  The  average 
bodily  temperature  is  subnormal.  Certain  cases  of  chronic 
edema  of  the  face  following  recurrent  erysipelas  should  be 
carefully  differentiated  by  the  history,  and  the  exclusive 
localization  of  the  process  in  the  one  locality. 

Treatment. — The  treatment  is  by  thyroid  feeding,  as 
originally  suggested  by  Murray,  or  the  more  recently 
introduced  thyroidin.  Small  doses  should  be  used  in  the 
beginning.  Protonuclein  has  also  been  advised. 


ATROPHIES. 

LEUCODERMA. 

Description. — Leucoderma,  vitiligo  or  "piebald  skin," 
which  must  be  distinguished  from  albinism,  is  an  acquired 
pigment  atrophy  of  the  skin,  characterized  by  variously 
sized  and  shaped,  smooth,  white,  non-elevated  patches, 
surrounded  by  hyperpigmented  borders. 

As  stated  above,  leucodermic  spots  have  different  shapes, 
being  more  or  less  round,  ovalish  or  irregular  in  outline. 
They  vary  from  finger-nail  to  palm-size  and  even  larger, 
especially  when  several  patches  have  run  together.  The 
color  is  generally  a  milky-white,  although  sometimes  with 
a  pinkish  tint.  Hairs  occurring  in  their  areas  may  be 
white,  or  else  retain  their  natural  color.  The  skin,  with  the 
exception  of  its  pigmentless  condition,  is  normal,  both 
objectively  and  subjectively.  Around  the  patches  the  skin 
is  very  much  darker,  owing  to  an  excess  of  coloring  matter 
in  these  situations.  Leucoderma  is  generally  symmetrical, 
and  is  most  usually  found  upon  the  sides  of  the  neck,  face, 
about  the  hips,1  the  backs  of  the  hands,  and  the  extremities. 
The  disease  is  always  worse  in  summer,  or,  rather,  it  is  more 
conspicuous  at  that  season,  owing  to  a  more  decided  con- 
trast between  the  pigmented  and  non-pigmented  portions 
of  the  skin.  The  disorder,  that  is  the  symmetrical  form, 
tends  to  steady  progression,  finally  involving  the  whole 
body,  and  sometimes  in  this  way  abolishing  the  lines  of 
demarcation  between  the  light  and  dark  parts  of  the  skin. 
In  two  cases  under  our  care,  one  of  which  occurred  in  a 
negro,  the  leucoderma  became  absolutely  universal.  Often 
the  progress  is  stayed  for  a  longer  or  shorter  time,  and 
sometimes,  although  rarely,  the  pigment  may  be  renewed. 

Both  sexes  are  said  to  be  affected  equally. 

1  The  spots  are  rarely  absent  from  this  situation. 


226  ATROPHIES 

The  disease  generally  makes  its  appearance  some  time 
between  the  tenth  and  thirtieth  years,  but  we  have  seen 
it  as  early  as  the  fourth  year  in  one  case,  and  in  others  in  the 
eighth.  The  etiology  of  leucoderma  is  obscure,  and  we 
must  content  ourselves  at  present  with  regarding  it  as  due 
to  some  disturbance  of  innervation.  Cheatle  has  called 
attention  to  the  frequent  coincidence  of  the  starting  points 
of  the  disease  with  Head's  maximum  points. 

Prognosis. — It  will  be  seen  from  the  foregoing  account 
that  the  prognosis  is  unfavorable,  although  it  is  proper  to 
state  that  in  rare  instances  the  pigment  has  been  known 
to  return. 

Treatment. — Little  or  nothing  can  be  accomplished  by 
drugs,  either  internally  or  locally.  We  have  never  seen  any 
good  come  from  the  use  of  arsenic,  iron,  etc.  McGowan 
has  given  adrenalin.  With  several  willing  patients  we  have 
tried  all  manner  of  stimulating  local  applications,  viz., 
electricity,  the  sun  glass,  blisters,  chrysarobin  applications, 
etc.,  but  all  without  permanent  effect.  It  is  quite  possible, 
however,  to  ameliorate  the  disfigurement  by  getting  rid, 
temporarily,  of  the  hyperpigmented  borders,  or  by  staining 
the  white  parts  with  some  brown  pigment.  Dr.  Savill 
paints  the  brown  patches  with  pure  phenol.  This  depig- 
mentation  may  be  secured  also  by  the  use  of  the  white 
precipitate  and  bismuth  salve  advised  in  freckles.  Cutler 
recommends  the  following  combination: 

1$ — Resorcini 5j 

Hydrarg.  chlor.  corros gr.  ij 

Acidi  acetici  diluti         oij 

Aquae q.  s.  ad     5ij — M. 

S. — Apply  over  the  pigmented  area  two  or  three  times  a  day  with 
a  camel's  hair  brush. 

Ullmann  obtained  good  results  with  the  ar-ravs. 

Montgomery,  of  San  Francisco,  greatly  benefited  one 
ease  by  phototherapy. 

Faradism,  and  galvanism  with  the  negative  electrode  to 
the  affected  area  have  been  recommended. 


PERFORATING  ULCER  227 


ATROPHIA  CUTIS. 

Description. — Aside  from  the  various  atrophies  of  the 
appendages  of  the  skin  and  of  the  pigment,  and  the  atro- 
phies connected  with  a  number  of  cutaneous  diseases,  the 
treatment  of  which  has  been  given  in  other  places,  there  are 
certain  atrophic  states  of  the  skin  proper,  which  will  be 
merely  mentioned  here  since  for  the  most  part  they  are 
incurable. 

1.  Senile  atrophy  of  the  skin. 

2.  Diffuse  idiopathic  atrophy  of  the  skin. 

3.  Congenital  atrophy  of  the  skin. 

4.  Striae  et  maculae  atrophicse. 

5.  Kraurosis  vulvas. 

Treatment. — The  management  of  the  seborrheic  patches 
and  warty  growths  found  in  relation  with  senile  atrophy 
has  already  been  considered.  (See  Keratosis  Senilis.)  As 
regards  the  essential  changes  in  the  skin  of  old  people  there 
is,  as  a  matter  of  course,  no  treatment  beyond  attention  to 
ordinary  rules  of  hygiene.  Kraurosis  vulvae,  which  mani- 
fests itself  as  an  atrophy  of  the  genital  organs  in  women,1 
is  generally  regarded  as  incurable.  Heitzmann,  however, 
recommended  curetting  the  thickened  patches,  and  the 
subsequent  application  of  lotions  of  salicylic  acid  and 
pyrogallol.  Martin  and  others  advise  excision  of  the 
affected  parts.  In  a  case  quoted  by  Belot,  in  which  radio- 
therapy was  tried,  the  result  was  favorable. 


PERFORATING  ULCER. 

Description.— The  disease  which  goes  by  the  name  of 
"perforating  ulcer"  is  almost  invariably  connected  with 
some  affection  of  the  nervous  system,  and,  therefore, 
belongs  to  the  class  of  affections  due  to  trophie  disturbances. 

1  BeeOhmann-Dumemul,  Monatsh.  f.  prakf.  Perm.,  1S<)(),  vol.  x. 


228  ATROPHIES 

In  most  instances,  the  original  malady  has  been  locomotor 
ataxia  or  a  peripheral  neuritis,  such  as  arises  in  alcoholism, 
syphilis,  or  leprosy.  The  ulcer  usually  occurs  on  the 
plantar  surface  over  the  metatarsophalangeal  joint  of  the 
big  or  little  toe.  As  a  rule,  only  one  ulcer  exists,  but  cases 
have  been  seen  in  which  several  were  present.  Not  infre- 
quently the  ulcer  begins  as  a  suppuration  under  a  corn 
which  burrows  into  the  soft  tissues.  Finally,  the  corn  is 
detached  and  the  orifice  of  a  sinus  is  exposed,  which  often 
leads  down  to  dead  bone.  From  continual  pressure  in 
walking  the  edges  of  the  sinus  become  much  thickened. 
There  is  generally  no  pain  connected  with  perforating 
ulcer,  not  even  on  pressure.  There  are  usually  present,  in 
part,  other  evidences  of  neurotic  disturbance,  such  as 
anesthesia,  loss  or  deformity  of  the  nails,  tylosis,  etc. 

The  course  of  the  disease  is  slow,  but  progressive. 

Treatment. — In  the  management  of  perforating  ulcer  the 
essential  thing  is  prolonged  rest.  Proper  orthopedic 
appliances  might  be  indicated  in  some  cases.  Treves 
recommends  paring  down  the  thick  edges  and  filling  the 
sinus  with  a  cream  composed  of  salicylic  acid  and  glycerin, 
to  which  2  per  cent,  of  carbolic  acid  has  been  added. 
Curetting  and  excision  are  advised.  After  healing,  a  thick 
felt  pad,  cut  out  over  the  scar,  is  to  be  worn,  and  every 
precaution  taken  to  prevent  fresh  injury.  Amputation  is 
sometimes  necessary.  Stretching  the  sciatic  nerve  has 
been  strongly  advocated. 


AINHUM. 

Description. — This  is  a  very  unusual  and  peculiar  affec- 
tion, which  for  a  while  was  thought  to  be  confined  to  the 
negro,  but  recently  cases  have  been  observed  in  India.  So 
far  as  recorded,  no  white  person  has  ever  been  affected  by 
it.  In  the  majority  of  cases  the  initial  symptom  is  a  furrow 
on  the  line  of  the  digitoplantar  fold  of  the  little  toe;  this 
furrow  gradually  becomes  deeper,  and  the  toe  assumes  ;m 


AINHUM  229 

ovoid  shape,  having  increased  to  two  or  three  times  its 
normal  size.  The  furrow,  as  it  increases  in  depth,  finally 
forms  a  circle  around  the  toe  until  the  member  is  attached 
by  a  mere  pedicle.  As  a  rule,  there  is  neither  pain,  inflam- 
mation nor  ulceration,  but  when  ulceration  does  occur  the 
pain  may  be  severe.  The  etiology  is  obscure. 

Treatment. — It  is  stated  that  if  in  the  beginning  the 
constricting  ring  is  cut  across  at  right  angles  the  advance 
of  the  disease  may  be  stayed.  When,  however,  the  con- 
stricting band  has  completely  encircled  the  member,  ampu- 
tation is  demanded. 


NEW  GROWTHS. 

KELOID. 

Description. — Keloid  is  a  fibrous  new  growth  of  the  corium 
which  usually  follows  injuries.  The  lesions  of  keloid  con- 
sist of  variously  sized  elevations  which  rise  abruptly  from 
the  healthy  skin.  The  integument  over  such  growths  is 
smooth,  shining,  and  somewhat  stretched ;  it  may  be  of  the 
hue  of  the  surrounding  skin,  or  of  a  pink  color. 

The  tumors  have  various  shapes,  but  usually  present 
claw-like  prolongations  around  the  periphery.  To  the 
finger,  keloid  is  firm,  but  not  hard.  The  most  common 
site  of  the  disease  is  over  the  sternum,  but  it  may  occur 
upon  any  part  of  the  body.  One  keloid  alone  is  usually 
present,  but  if  the  disease  has  developed  from  the  scars  of 
a  generalized  eruption,  such  as  smallpox,  there  may  be 
large  numbers  upon  the  body.  In  some  cases  the  tendency 
is  to  slow  but  steady  progression,  but  in  others,  after 
reaching  a  certain  size,  the  growth  remains  stationary. 
Keloid  sometimes  undergoes  involution.  Most  keloids 
are  tender  on  pressure,  and  in  some  there  is  spontaneous 
pain  of  a  burning  or  pricking  character. 

A  condition  resembling  keloid  in  many  of  its  aspects 
is  the  hypertrophied  scar.  This  condition  is  most  apt  to 
occur  where  a  wound  of  the  skin  has  not  healed  by  first 
intention.  There  is  an  overproduction  of  scar  tissue, 
resulting  in  a  raised,  reddish  or  white,  generally  smooth 
and  shining  cicatrix.  If  the  wound  was  sutured,  there  are 
very  apt  to  be  prolongations  of  the  scar  about  the  suture 
points,  which  make  the  hypertrophied  scar  much  resemble 
keloid. 

The  negro  race  is  especially  prone  to  keloid,  and  among 
them  hypertrophied  scar  is  very  common.  It  is  very  likely 
that  keloid  is  always  the  result  of  an  injury,  the  trauma 


KELOID  231 

being  so  slight  as  to  pass  unnoticed  in  those  cases  where 
the  disease  seems  spontaneous. 

Prognosis. — This  is,  as  a  rule,  unfavorable,  although 
cures  have  been  effected  in  some  cases,  and  in  others  the 
growths  have  spontaneously  diminished  in  bulk,  or  dis- 
appeared. 

Treatment. — The  treatment  of  keloid  by  internal  reme- 
dies is  generally  negative,  although  arsenic  and  thyroid 
extract  (Stel wagon)  have  been  employed.  The  removal 
of  keloid  by  the  knife  or  caustics  is  unsatisfactory,  as  the 
growth  nearly  always  recurs,  often  in  an  aggravated  form. 
The  arrays  should  be  tried  first  in  all  cases  of  keloid,  espe- 
cially in  large  growths.  It  has  the  advantage  of  painlessness, 
and  is  no  more  tedious  than  other  forms  of  treatment. 
Our  own  results  have  been  variable,  but  encouraging  upon 
the  whole,  and  as  Belot  remarks,  while  the  treatment  is 
not  infallible,  it  usually  gives  satisfactory  results.  Belot 
advises  that  a  violent  reaction  should  be  avoided,  and  states 
that  he  seldom  exceeds  a  dose  of  6  H.  or  7  H.  repeated 
every  fifteen  or  twenty  days.  We  have  employed  the  o>rays 
in  keloid  with  partial  success  in  about  the  same  manner  as 
that  used  in  epithelioma  (q.  v.}.  Pusey,  in  many  cases  of 
keloid  and  hypertrophied  scar,  never  failed  to  get  great 
improvement  or  complete  flattening  by  this  method.  As 
suggested  by  one  of  us1  many  years  ago,  and  confirmed 
by  others,  notably  Brocq  and  Crocker,  electrolysis,  while 
tedious  and  painful,  gives  at  times  quite  good  results. 
Today  we  reserve  its  use  for  small  growths.  The  pro- 
cedure is  the  same  as  for  the  removal  of  hair,  etc. 
We  attach,  however,  to  the  negative  pole  a  tolerably 
stout  sewing  needle,  No.  10  or  11.  This  is  plunged 
through  the  keloid  in  various  directions,  making  parallel 
as  well  as  perpendicular  thrusts,  and  also  passing  the 
needle  some  distance  beyond  the  apparent  boundaries 
of  the  growth.  A  current  of  5  or  more  ma.  should 
be  employed.  Sinclair  Tousey  has  employed,  with  sat- 

1  Hanlawav. 


232  NEW  GROWTHS 

isfactory  results,  from  10  to  15  minims  of  a  10  per 
cent,  solution  of  thiosinamin  hypodermically.  G.  T. 
Jackson,  however,  reports  unfavorably  on  this  method. 
Marie  and  others  have  advocated  the  injection  into  the 
tumor  of  a  20  per  cent,  solution  of  creosote  in  olive  oil. 
Verneuil  employed  pressure  with  the  elastic  bandage. 
Various  palliative  measures  have  been  recommended,  such 
as  the  application  of  mercurial  plaster,  lead  ointments, 
etc.  Brocq  believes  that  pain  may  be  relieved  by  linear 
scarification.  Stelwagon  advises,  as  a  means  of  relieving 
the  pain  and  itching,  and  probably  retarding  the  growth  of 
keloid,  an  application  of  the  following  sort: 

1$ — Acidi  salicylic! gr.  x-xx 

Empl.  plumbi, 

Empl.  saponis aa  oiij 

Petrolati q.  s.  ad  5j— M. 

To  this  ointment  may  be  added  from  1  to  2  drachms  of 
ichthyol. 

For  the  relief  of  the  subjective  symptoms  present  in 
keloid,  we  may  employ  menthol  in  solution  or  salve, 
belladonna,  or  even  morphine,  hypodermically.  The  effect 
of  the  x-rays  is  marked. 


CICATRIX. 

Description. — A  scar  is  a  new  formation  of  dense  con- 
nective tissue  replacing  a  destruction  extending  below  the 
uppermost  parts  of  the  corium.  While  well  worthy  of 
study  for  their  diagnostic  import,  we  are  in  this  work  only 
concerned  with  such  scars  as  call  for  therapeutic  interfer- 
ence. These  include:  (1)  hypertrophied  scars;  (2)  those 
producing  distortion  of  natural  orifies;  (3)  those  which 
immobilize  joints;  (4)  disfiguring  scars  upon  the  face;  (5) 
certain  scars  presenting  abnormal  vascularity;  (6)  painful 
or  itching  scars. 

Hypertrophied  scars  are  considered  in  this  work  in  the 
article  on  keloid.  Those  in  the  second  and  third  classes 


FIBROMA  233 

may  be  benefited  by  the  methods  there  advised,  but  generally 
demand  surgical  procedures,  such  as  excision  with  loosen- 
ing up  of  the  edges,  grafting,  or  a  plastic  operation.  Varney 
claims  to  have  benefited  pits  left  upon  the  face  after  small- 
pox or  acne  by  pushing  the  use  of  the  ar-rays  to  the  point 
of  obtaining  a  moderate  reaction.  Something  might  be 
accomplished  by  means  of  paraffin  injections. 

Excessive  vascularity  will  usually  yield  to  time.  Large 
vessels  which  remain  may  be  destroyed  by  electrolysis. 

Pain  and  itching  will  often  be  relieved  by  the  x-rays,  but 
may  call  for  excision  followed  by  grafting. 


DERMATITIS  PAPILLARIS  CAPILLITII. 

Description. — This  is  a  chronic  disease  of  hairy  regions, 
consisting  of  firm,  vascular  papules,  which  by  their  growth 
and  coalescence  form  rounded  or  lobulated  tumors  of  pea 
to  bean  size,  gradually  flattening  down  into  keloid-like 
masses. 

This  disease  is  more  often  seen  in  negroes,  and  in  adult 
males  of  this  race.  It  affects  chiefly  the  posterior  margin 
of  the  scalp,  extending  into  the  hair  and  down  the  back  of 
the  neck,  with  a  preference  for  the  middle  line.  There  are 
generally  one  or  more  larger  growths  midway  of  the  hairy 
margin,  with  smaller  lesions  toward  the  periphery  of  the 
group. 

Prognosis. — The  disease  shows  a  marked  tendency  to 
recurrence. 

Treatment. — The  growth  may  be  dealt  with  by  excision, 
the  ekrtrorautery  or  electrolysis.  Scarification  may  be 
employed,  as  advised  under  Keloid.  Pusey  found  the 
o>rays  of  value. 

FIBROMA. 

Description. — Small  fibromatous  growths  are  not  uncom- 
mon in  the  skin;  they  are  usually  few  in  number,  of  small 
size,  and  give  rise  to  no  especial  inconvenience. 


234  NEW  GROWTHS 

In  that  form  of  fibroma  molluscum  known  as  multiple 
fibroma  the  tumors  vary  in  size  from  a  split  pea  up  to 
the  dimensions  of  an  egg  or  larger.  They  also  differ 
much  in  shape,  consistence,  and  other  physical  characters. 
Some  are  rounded  and  embedded  in  the  tissues,  or  else 
they  may  be  pendulous  and  pedunculated,  and  assume 
various  shapes;  they  may  feel  soft  and  gelatinous,  or  hard 
or  fibrous;  the  overlying  skin  may  be  normal  in  color, 
pinkish  or  pigmented,  and  it  may  be  loose  or  stretched; 
and  finally  the  lesions  may  be  occupied  by  a  few  hairs,  and 
one  or  several  comedones  may  be  visible. 

Among  the  other  growths,  here  and  there,  are  to  be 
observed  some  that  are  flaccid  and  empty,  "like  a  little 
purse,  out  of  which  the  money  has  vanished."  The  tumors 
may  be  numbered  by  the  hundred  or  thousands,  and 
exhibit  all  grades  of  development.  In  some  cases  the 
tumors  undergo  involution,  but,  as  a  rule,  they  continue 
to  increase  in  size  and  number. 

The  patient  makes  no  complaint  of  subjective  symp- 
toms, and  relief  is  sought  only  for  the  removal  of  the 
unsightliness  and  inconvenience  of  the  disorder. 

Fibroma  pendulum  usually  occurs  as  a  solitary,  pendu- 
lous, pear-shaped  tumor,  most  frequently  situated  on  the 
face  or  neck,  or  near  the  groin  or  axilla.  Sometimes 
these  growths  are  of  an  enormous  size,  and  cause  great 
annoyance  to  the  unfortunate  person  bearing  them. 

Von  Recklinghausen  states  that  the  multiple  fibromata 
of  the  skin  are  in  reality  neurofibromata. 

Treatment. — Whitehouse  gave  arsenic  in  the  form  of 
Asiatic  pills  in  a  case  of  multiple  fibromata,  with  the  result 
that  a  large  number  of  tumors  disappeared,  but  such  an 
experience  is  exceptional,  and  the  treatment,  if  practicable 
at  all,  is  surgical. 

The  treatment  of  the  large,  pendulous  masses  and  flaps 
of  skin  is  surgical.  The  smaller  tumors  may  be  snipped 
off  with  scissors  or  removed  by  electrolysis,  ecrasement, 
ligation,  or  the  galvanocautery. 


NEUROMA  235 


MYOMA. 

Description. — Myoma  of  the  skin  occurs  as  small,  multiple 
growths,  or  as  a  single  larger  tumor.  The  first  variety  is 
very  rare,  only  12  cases  having  been  reported.  The  affec- 
tion occurs  as  patches  of  lenticular-shaped  tumors,  the 
skin  over  which  may  be  normal  in  color  or  more  com- 
monly of  a  reddish  hue.  Nearly  all  the  cases  have  been 
accompanied  by  pain,  either  spontaneous  or  provoked  by 
pressure.  Some  of  the  lesions  may  undergo  involution, 
but  the  tendency  is  to  slow  progression. 

The  large,  single  myomata  are  not  so  rare.  They  occur 
as  variously  sized  tumors,  sessile  or  pedunculated,  chiefly 
on  the  breasts  and  genitals.  Such  tumors  are  very  slow 
growing,  and  do  not,  as  a  rule,  cause  pain. 

The  only  method  of  treatment  for  myomata  is  ablation, 
which  is  often  demanded  by  the  pain  of  the  tumors.1 


NEUROMA. 

Description. — Under  this  name  there  have  been  described, 
from  time  to  time,  tumors  of  the  skin  or  subcutaneous  tissue 
that  were  accompanied  by  more  or  less  pain,  often  of  a 
neuralgic  character.  On  microscopic  examination  such 
growths  have  usually  been  found  to  be  made  up  of  fibrous 
tissue  with  some  nerve  fibers. 

Duhring's  and  Kosinki's  cases,  which  are  usually  quoted 
as  examples  of  pure  cutaneous  neuromata,  were  treated  by 
removing  part  of  the  nerve  trunk  distributed  to  the  tumors. 

1  In  a  case  of  ours  first  published  in  the  American  Journal  of  the 
Medical  Sciences,  April,  1886  (Hardaway),  with  a  subsequent  report 
made  eighteen  years  afterward,  the  original  excised  patch  returned 
and  the  patient  developed  many  other  tumors.  The  x-ray  was  tried 
a  few  times,  apparently  giving  relief  to  the  pain,  but  the  patient 
refused  further  treatment. 


236  NEW  GROWTHS 


LIPOMA. 

Description. — The  larger  lipomata  come  under  the  care 
of  the  surgeon.  Smaller,  multiple  growths,  however,  may 
properly  be  considered  a  dermatological  condition.  This 
form  usually  possesses  a  dense,  fibrous  stroma  so  as  to  con- 
stitute more  properly  a  fibrolipoma.  Their  possessors  are 
usually  of  good  general  health  and  of  muscular  development 
above  the  average.  The  growths,  from  pea  to  small  egg 
size,  are  usually  scattered,  from  one-half  dozen  to  fifty  or 
more  in  number,  about  the  extremities.  They  are  seated  in 
the  lower  connective-tissue  structure  of  the  skin.  They  can 
be  recognized  by  their  chronicity,  painlessness,  multiplicity, 
distribution,  firmness,  and  generally  by  a  characteristic 
lobulated  feel. 

Treatment. — Ordinarily  treatment  is  not  required.  When 
troublesome,  by  reason  of  their  situation  or  unsightliness, 
they  may  be  excised. 

XANTHOMA. 

Description. — Xanthoma,  also  sometimes  called  xanth- 
elasma  and  vitiligoidea,  is  characterized  by  flat  or  ele- 
vated, buff-colored  lesions.  It  is  a  comparatively  rare 
disease.  Xanthoma  is  met  with  in  two  principal  varieties, 
the  plane  or  flat  form  (xanthoma  planum)  and  the  elevated 
or  tubercular  and  tuberose  form  (xanthoma  tuberculatum 
or  tuberosum).  In  some  instances  all  of  the  varieties  of 
the  disease  may  be  present  at  the  same  time  (xanthoma 
multiplex). 

Xanthoma  Planum. — In  this  form  of  the  disorder  the 
plaques,  of  a  yellow  or  buff  color,  are  only  slightly  if  at  all 
elevated  above  the  level  of  the  skin,  and  when  pinched  up 
between  the  fingers  the  patch  feels  smooth  and  without 
apparent  infiltration.  The  comparison  of  these  lesions  to 
chamois  leather  embedded  in  the  skin  is  quite  happy. 
Xanthoma  planum  occurs  mostly  on  the  skin  of  the  eye- 


XANTHOMA  237 

lids,  and  perhaps  more  frequently  on  the  upper  than  the 
lower  lids.  The  left  side  at  the  upper,  inner  angle  is  apt 
to  be  attacked  first,  but  symmetry  is  sooner  or  later  estab- 
lished. The  patches  on  the  lids  are  usually  present  in  the 
form  of  narrow  bands,  often  running  quite  across  from  one 
canthus  to  the  other.  Occasionally  a  series  of  patches 
may  surround  the  eyes  completely.  The  plane  variety  may 
develop  elsewhere. 

Xanthoma  Tuberculatum.— The  tubercular  form  is 
represented  by  variously  sized  growths,  ranging  from  the 
diameter  of  a  pin's  head  to  that  of  a  walnut,  or  even  larger. 

They  are  usually  of  the  same  color  and  consistence  as  in 
the  plane  variety,  but  are  sometimes  of  a  reddish  yellow. 
When  a  number  of  small  growths  have  coalesced,  the  result- 
ing tumor  is  lobulated,  and  perhaps  more  resistant  to  the 
touch.  The  tubercles  and  tumors  are  prone  to  develop  at 
sites  of  pressure  and  on  exposed  parts. 

Pain  is  sometimes  complained  of  in  this  form,  whereas 
in  xanthoma  planum  there  are  no  subjective  symptoms 
whatever. 

Xanthoma  Diabeticorum. — Under  the  name  of  xan- 
thoma diabeticorum  some  30  or  more  cases  of  a  peculiar 
form  of  xanthoma  have  been  reported.  Especial  attention 
was  called  to  it  by  Malcolm  Morris  in  1883.1  The  eruption 
consists,  according  to  Crocker,  of  dull-red,  firm,  discrete  or 
confluent  papules  from  a  line  to  one-sixth  of  an  inch  in 
diameter,  well  defined  at  the  margin  and  of  an  obtusely 
conical  or  roundish  shape.  On  the  top  of  most  of  them 
is  a  yellow  or  yellowish-white  head,  and  some  of  the  lesions 
are  dotted  and  streaked  with  red  from  the  presence  of 
capillary  vessels.  The  papules,  owing  to  this  coloration, 
simulate  pustules,  but  in  reality  they  are  solid.  The  usual 
sites  of  the  eruption  are  the  elbows,  knees,  and  buttocks, 
but  it  may  occur  anywhere  on  the  skin,  on  the  mucous  mem- 
brane of  the  mouth,  and  in  some  instances  on  the  eyelids. 

1  Pathological  Society  Transactions,  xxxiv.  Sec  Johnston  for  a 
full  bibliography.  Journal  Cutaneous  and  Genitourinary  Discuses, 
October,  1X<).~>. 


238  NEW  GROWTHS 

The  lesions  come  out  rapidly  at  first,  and  after  persisting 
for  a  variable  period — months  or  even  years — may  dis- 
appear as  rapidly,  leaving  no  mark  behind  them;  or,  again, 
new  lesions  may  appear  while  others  are  undergoing  involu- 
tion, or  they  may  all  disappear  for  a  season  to  reappear  at 
some  future  time.  Itching,  burning,  and  tenderness  may 
be  present.  With  a  few  exceptions  the  cases  have  all  been 
men  and  the  majority  of  patients  have  been  between  thirty 
and  forty  years  of  age.  There  has  been  a  history  of  sugar 
in  the  urine  in  most  instances,  but  not  in  all.  Pentose  was 
found  in  the  urine  in  one  case.  Sabouraud  says  of  this 
condition  that  it  may  be  true  xanthoma  or  a  "diabe'tide 
xanthalasmif  orme. " 

Prognosis. — The  course  of  the  disease  is  chronic,  and 
usually  the  lesions,  when  fully  established,  are  permanent. 
This  is  especially  true  of  xanthoma  palpebrarum.  The 
multiple  form  may  undergo  spontaneous  involution. 

In  diabetic  xanthoma  the  prognosis  is  favorable. 

Treatment. — The  treatment  of  xanthoma  of  the  lids  is 
entirely  local.  Sabouraud '  speaks  so  positively  of  the 
curative  effects  of  the  galvanocautery  that  we  shall 
mention  it  first.  He  makes  a  series  of  punctures  with  a 
galvanocautery  2  to  3  mm.  apart  and  at  intervals  of  a 
fortnight.  He  asserts  that  the  lesions  disappear  at  the 
conclusion  of  three  such  treatments.  G.  H.  Fox  first 
recommended  electrolysis  for  the  removal  of  xanthoma  pal- 
pebrarum, and  we  have  made  use  of  this  method  for  many 
years.  A  fine,  stiff  sewing  needle  should  be  employed, 
attached  to  the  negative  electrode,  using  a  current  of  1  to 
5  ma.,  although  we  must  repeat  that  experience  in  the  use 
of  electrolysis  is  a  better  guide  than  any  instrument  of  pre- 
cision. The  needle  should  be  passed  from  side  to  side  and 
deeply,  there  being  but  little  fear  of  any  marked  scarring. 
Superficial  puncture  removes  the  growth  only  temporarily, 
and  the  same  may  be  said  of  applications  of  trichloracetic 
acid.  Pusey  suggests  deep  freezing  under  pressure  for  ten 
or  fifteen  seconds,  with  liquid  air  or  solid  carbon  dioxide. 

The  use  of  corrosive  sublimate,  10  per  cent.,  in  collodion 


ANGIOMA  239 

(Stern)  is  not  to  be  advised.  Excision  is,  we  believe,  the 
favorite  method  of  treatment  with  ophthalmologists.  In 
a  case  of  xanthoma  multiplex  Morrow  applied  a  25  per 
cent,  salicylic  acid  plaster  to  nodules  on  the  soles  and 
knees,  which  after  being  worn  for  several  days  was  removed, 
the  softened  tissues  coming  away  with  it,  and  a  simple 
diachylon  plaster  put  on.  I^eslie  Roberts  used  the  follow- 
ing paint  on  some  palmar  lesions : 

1$ — Acidi  salicylici 5j 

Chrysarobini 5ss 

Olei  ricini 5ss 

Collodii  flex q.  s.  ad  5j — M. 

The  ar-rays  and  the  high-frequency  current  have  also  been 
employed.  The  former  failed  with  one  of  us  after  a  thor- 
ough trial.  Evans  and  Whitehouse  had  better  success. 
In  diabetic  xanthoma  the  glycosuria  should  receive  the 
usual  dietetic  and  medicinal  treatment,  and  the  accompany- 
ing pruritus  should  be  palliated  by  menthol  or  other 
similar  remedies. 

ANGIOMA. 

Description. — In  a  general  way  an  angioma  may  be 
defined  as  a  condition  of  the  skin  in  which  there  is  new 
growth  or  permanent  dilatation  of  bloodvessels.  It  is  diffi- 
cult to  give  a  clear  definition  of  the  angiomata  from  an 
anatomical  standpoint,  but  for  clinical  purposes  the  fol- 
lowing classification  will  fbe  found  sufficient : 

Angioma  Simplex. — According  to  Unna,  this  is  the 
most  frequent  type  of  cutaneous  angioma.  It  is  usually 
congenital,  first  appearing  as  a  small  point,  but  afterward 
it  grows  more  or  less  rapidly  and  may  assume  enormous 
proportions,  whereas  the  angiomatous  nevi  grow  merely 
with  the  growth  of  the  body.  Simple  angiomas  are 
usually  found  on  the  head  or  neck,  or  about  the  trunk 
and  extremities;  even  the  mucous  membranes  are  not 
exempt. 

They  vary  from  hemp-seed  to  cherry-stone  or  walnut 


240  NEW  GROWTHS 

size,  or  they  may  occupy  quite  extensive  areas.  They 
are  bluish-black  or  bluish-red  in  color,  at  first  usually  level 
with  the  skin  and  smooth  to  the  touch;  but  later  they  be- 
come compressible,  and  somewhat  irregular  and  lumpy  in 
appearance.  At  times  they  undergo  involution,  or  cystic 
or  cavernous  changes  may  occur.  Sometimes  marked 
pulsation  may  be  observed.  Variations  in  size  and  color 
may  also  be  noted  at  times. 

Various  complications  may  occur;  the  skin  covering 
the  tumor  may  ulcerate  and  alarming  hemorrhage  ensue, 
or  gangrene  may  develop. 

Angioma  Cavernosum. — The  true  primary  cavernous 
angiomata  (Winiwarter)  are  diffuse  or  defined  soft  tumors, 
lobular  or  hemispherical,  and  of  a  bluish  or,  less  rarely,  Ted 
color.  They  diminish  under  compression,  or  again  be- 
come turgid  when  pressure  is  exerted  about  them.  When 
encapsulated  they  are  movable  under  the  skin.  They  are 
frequently  painful.  They  are  usually  seated  under  the 
skin,  and  rarely  multiply.  They  most  often  appear  during 
the  first  year  of  life,  and  sometimes  in  response  to  some 
traumatism.  They  grow  slowly,  but  at  times  they  invade 
the  soft  tissues  extensively  and  attack  bone  and  cartilage. 

Naevus  Vascularis. — The  term  vascular  nevus,  used 
in  the  sense  of  port-wine  mark,  feuermal,  tache  de  feu, 
nsevus  flammeus,  etc.,  represents  an  exceedingly  com- 
mon disorder.  It  is  usually  congenital.  It  may  appear 
as  a  flat  or  elevated  patch  of  a  bright-red  or  claret  color  and 
occupy  only  a  small  extent  of  surface,  or  be  spread  over 
large  areas.  The  integument  may  be  quite  smooth,  thin,  or 
else  present  numerous  rugosities  and  considerable  hyper- 
trophy. Little  polypoid  growths,  darker  in  color  than  the 
nevus  itself,  are  sometimes  scattered  over  the  affected 
region.  The  color  of  the  nevus  may  be  made  to  change  by 
pressure  or  under  the  influence  of  position.  A  common 
site  of  these  growths  is  the  face,  and  they  are  usually 
unilateral. 

Telangiectases. — These  develop  as  primary  or  second- 
ary phenomena,  although  at  times  it  is  difficult  to  determine 


ANGIOMA  241 

their  cause.  The  usual  sites  are  the  face,  neck,  and  upper 
part  of  the  trunk.  A  common  clinical  form  is  the  naevus 
araneus,  or  spider  cancer,  in  which  there  is  a  central  red 
spot  with  radiating  lines.  In  other  cases  small,  red  or 
bluish  vessels  are  seen  coursing  over  the  skin.  These  are 
frequently  seen  upon  the  cheeks  and  nose  in  elderly  per- 
sons. In  some  rare  instances  almost  the  whole  body  may 
be  covered  by  telangiectases.  Telangiectases  are  also 
seen  on  mucous  membranes  or  about  the  nares,  the  ocular 
conjunctiva,  and  the  pharynx.  Telangiectases  may  result 
from  any  cause  that  produces  long-continued  congestion  of 
the  skin,  such  as  interstitial  changes  in  the  kidney  or  liver, 
emphysema  or  other  lung  affections.  Local  obstruction 
to  the  cutaneous  circulation  also  causes  them;  hence  they 
are  found  at  the  periphery  of  scars  and  over  new  growth. 
Telangiectases  constitute  the  essential  features  of  rosacea 
in  the  second  stage. 

Treatment. — Very  superficial,  reddish  stains  occasionally 
seen  on  the  faces  of  children  at  birth,  and  sometimes  the 
small,  simple  angiomata,  undergo  retrogression.  Both 
Crocker  and  Stelwagon  recommend  painting  on  several 
layers  of  collodion  for  some  days  or  weeks,  or  the  use  of 
continuous  pressure  when  the  lesion  is  over  a  bony  prom- 
inence. This  treatment  is  of  no  avail  unless  instituted 
within  the  first  few  days  of  life.  Brushing  over  the  growth 
with  liquor  plumbi  subacetatis  (Bligh)  has  also  appeared 
useful. 

Electrolysis  is,  however,  by  far  the  best  method  of  treat- 
ment in  small  capillary  nevi. 

As  the  patients  are  usually  infants,  general  anesthesia  is 
essential.  The  positive  electrode,  suitably  covered,  is 
applied  to  some  indifferent  part  of  the  body  by  an  assistant, 
and  a  medium-sized  sewing  needle,  which  has  been  attached 
to  the  negative  electrode,  is  thrust  directly  or  somewhat 
obliquely  into  the  growth;  or  sometimes  moved  from 
place  to  place.  After  the  current  has  been  allowed  to  act 
for  a  few  minutes  the  positive  electrode  is  released  and  the 
needle  withdrawn.  The  strength  of  the  current  to  be 
16 


242  NEW  GROWTHS 

employed,  the  number  of  punctures  required,  the  kngth 
of  the  sitting,  etc.,  are  matters  to  be  determined  by  the 
nature  of  the  lesion.  In  small  growths,  mild  currents — 1 
to  5  ma. — and  one  sitting,  are  all  that  are  necessary  for 
obliteration. 

For  large  nevi  bipolar  electrolysis  may  be  employed. 
The  needles  may  be  placed  parallel  and  equidistant  from 
each  other  and  from  the  sides  of  the  tumor,  or  the  positive 
needle  may  be  placed  in  the  centre  of  the  growth,  and  the 
negative  needle  may  be  moved  from  place  to  place  or 
reintroduced  at  other  points.  In  large  nevi  not  too  much 
should  be  done  at  each  operation,  and  it  is  best  to  have  an 
interval  of  some  weeks  between  sittings,  so  that  results  can 
be  more  accurately  gauged  and  unnecessary  destruction 
avoided.  Duncan,  of  Edinburgh,  one  of  the  earliest  advo- 
cates of  electrolysis  in  nevus,  used  steel  needles  insulated 
with  vulcanite,  the  exposed  points  varying  from  one-eighth 
to  one-quarter  of  an  inch.  The  positive  needle  may  be  of 
gold  or  iridoplatinum,  since  those  of  steel  undergo  oxidation. 
For  adults  general  anesthesia  is  usually  unnecessary  if  the 
electrolysis  is  done  a  little  at  a  time  and  the  current  is 
properly  interrupted.  (See  Hypertrichosis.) 

Innumerable  other  methods  of  treating  angiomata  have 
been  recommended  from  time  to  time,  and  many  of  these 
procedures  have  their  advantages  for  certain  cases.  Thus, 
according  to  the  size,  location,  and  other  features  of  the 
growth  we  may  make  trial  of  excision,  the  ligature,  the 
application  of  caustics,  etc.  The  injection  of  irritants  into 
the  growth  and  vaccination  over  the  lesion  are  not  to  be 
recommended.  We  have  seen  some  excellent  results  in 
extensive  nevus  from  Wyeth's  hot-water  method,  but  it 
requires  great  care  in  the  administration  and  may  <^ive 
rise  to  some  very  ugly  after-effects.  Gottheil  thinks  well 
of  the  galvanocautery,  and  has  devised  an  excellent 
instrument  that  may  be  used  for  this  or  similar  purposes. 
The  high-frequency  current  applied  by  means  of  the 
carbon-pointed  electrode  has  also  been  employed  by 
Bulkley. 


A. \GIOM  A  243 

Various  methods  have  been  recommended  for  the  re- 
moval of  port-wine  mark,  such  as  linear  scarification, 
tattooing  with  needles  dipped  in  carbolic  acid,  etc.  Some 
years  ago  one  of  us1  advised  the  employment  of  electrolysis 
in  this  affection  also,  and  this  procedure  still  holds  the 
first  place  in  our  estimation.  In  many  cases,  where  small 
and  very  superficial  nevi  are  concerned,  the  blemish  may  be 
entirely  abolished,  and  in  other  instances,  of  more  extensive 
involvement,  we  are  quite  safe  in  promising  considerable 
amelioration.  The  operation  presently  to  be  described 
has  especial  reference  to  flat  nevi  of  considerable  extent. 

The  modus  operand!  consists  in  the  use  of  a  needle  or 
needles,  placed  in  a  suitable  holder,  which  latter  is  attached 
to  the  negative  pole  of  a  galvanic  battery.  The  successive 
steps  of  the  operation  are  the  same  as  those  described  in 
connection  with  the  removal  of  superfluous  hairs.  (See 
Hypertrichosis.)  The  most  important  point  relating  to  any 
destructive  operation  upon  the  skin  is  that  the  operator 
should  control  the  destroying  agent  as  much  as  possible. 
The  facility  with  which  this  end  is  accomplished  in  elec- 
trolytic methods  constitutes  one  of  its  chief  merits.  In 
order,  therefore,  to  control  this  destruction  in  the  most 
satisfactory  way,  we  have  for  a  long  time  discarded  the 
bundle  of  needles  and  make  the  electrolytic  puncture 
with  one  only. 

By  the  cautious  and  expert  use  of  this  one  needle  we 
no  longer  set  up  extensive  areas  of  suppuration,  as  was 
apt  to  be  the  case  with  the  crown  of  needles;  and  since 
employing  the  single  needle  we  have  no  fear  of  the  keloidal 
scars,  which  sometimes  followed  the  introduction  of  the 
bundle.  The  operation  is  thereby  rendered  somewhat 
more  tedious,  but  certainly  safer.  It  is  a  tedious  thing  to  do 
at  best,  for  when  the  puncture  is  made  the  surrounding 
region  becomes  so  blanched  that  we  are  at  something  of  a 
loss  to  know  exactly  where  to  make  the  next  one  to  the 
best  advantage,  and  the  next  day,  for  quite  a  space  around 

1  Hanlaway. 


244  NEW  GROWTHS 

the  place  operated  upon,  there  is  an  inflammatory  areola, 
and  perhaps  crusting,  which  forces  us  to  wait  for  a  number 
of  days  before  operating  again.  One  cannot  really  form  an 
estimate  of  the  result  in  a  given  area  until  at  least  six  weeks 
or  two  months  afterward;  and  when  all  the  space  that  one 
intends  working  upon  has  been  gone  over,  the  patient 
should  be  dismissed  for  a  season.  No  one  pretends  for 
a  moment  that  in  a  port-wine  mark  of  any  magnitude 
this  operation  will  leave  a  normal  skin  behind  it.  In  the 
majority  of  cases  we  aim  to  produce  minute,  multiple 
scars,  which  in  time  become  white,  and  thus  obliterate  the 
nevus. 

It  often  happens,  however,  that  a  large  area  is  perma- 
nently blanched  without  scar  by  apparent  obliteration  of 
vessels  at  its  periphery.  In  some  cases  intense,  brown 
pigmentation  takes  the  place  of  the  red  surface,  which, 
however,  gradually  undergoes  absorption,  leaving  the 
skin  white.  This  generally  occurs  on  parts  where  the  skin 
is  thin.  Where  one  needle  is  employed  the  resulting  scars 
are  usually  thin,  supple,  non-depressed,  in  no  case  leaving 
behind  elevated  knots  and  cords  such  as  sometimes  result 
from  the  galvanocautery. 

Very  often  it  is  better,  in  a  cosmetic  way,  to  endeavor 
merely  to  lighten  the  color  of  the  mark,  rather  than  to  con- 
vert it  into  a  dead-white  patch;  of  course,  where  the  mark 
is  quite  small,  a  thin,  white,  and  even  glistening,  cicatrix  is 
not  especially  objectionable.  It  is  not  uncommon  to  find 
that  in  an  apparently  obliterated  wine  stain  dot-like  telan- 
giectases  will  after  awhile  appear  here  and  therp.  They 
must  be  again  destroyed.  After  a  good  many  years' 
experience  we  may  add  that  while  this  operation  is  by  no 
means  ideal,  it  is  perhaps  better,  in  suitable  cases,  than 
anything  else  at  our  command. 

The  following  procedure  is  advised  by  Dr.  L.  L.  Mc- 
Arthur.  A  thin  layer  of  skin  is  dissected  off  the  nevus, 
going  just  deep  enough  to  include  the  capillaries  of  the 
corium,  which  are  thus  obliterated  in  the  resulting  scar. 
Thiersch  grafts  are  immediately  applied.  Pusrv  suggests 


ANGIOMA  245 

freezing  flat  lesions  with  liquid  air  or  carbon  dioxide.  "A 
small  area,  from  ^  to  f  of  an  inch  in  diameter,  is  frozen 
by  the  application  of  liquid  air  or  solid  carbon  dioxide  for 
five  or  ten  seconds.  The  depth  of  the  freezing  depends 
upon  the  amount  of  pressure  exerted,  and  requires  some 
care  to  gauge  it  correctly.  After  the  freezing  there  is 
violent  reaction,  which  persists  for  about  ten  days,  and  is 
followed  by  very  slight  scarring  and  destruction  of  all  or 
a  great  part  of  the  bloodvessels." 

Phototherapy  was  recommended  by  Finsen.  Out  of  10 
cases  of  the  plane  form,  he  obtained  cure  of  1  and  improve- 
ment of  the  others.  The  results  so  far  have  not  been  espe- 
cially brilliant,  although  Heidingsfeld  and  Allen  have 
reported  good  results.  The  same  may  be  said  of  the  avrays. 
Belot's  conclusion  seems  to  be  a  sound  one,  namely,  where 
electrolysis  gives  good  results  it  should  be  preferred  to 
radiotherapy,  since  the  application  of  the  former  is  simpler, 
safer,  and  less  expensive,  although  Pfahler  believes  that  the 
latter  gives  results  at  least  equal  to  any  other.  Jutassy, 
Schamberg,  and  Pusey  have  had  excellent  results  by  pro- 
ducing an  acute  dermatitis.  The  utilization  of  the  Finsen 
light  is  practically  impossible  for  the  general  physician. 
Holzknecht  used  radium  successfully  in  a  flat  port-wine 
mark. 

The  treatment  of  telangiectases  is  fully  described  under 
acne  rosacea  and  need  not  be  given  here. 

Nothing  acts  so  well  in  the  naevus  araneus,  or  spider  nevus, 
as  electrolysis.  The  negative  needle  is  introduced  in 
the  central  spot,  and  a  weak  current  is  allowed  to  pas^  for 
a  few  seconds.  Sometimes  it  is  also  necessary  to  puncture 
the  vessels  diverging  from  the  central  point.  Occasionally 
the  operation  has  to  be  repeated,  but  it  is  better  to  make 
several  operations  than  run  the  risk  of  a  scar.  Once  in  a 
while  a  considerable  ecchymosis  occurs  after  the  operation, 
which  will  alarm  the  inexperienced,  but  it  is  of  no  eon- 
sequence  and  presently  disappears. 


246  NEW  GROWTHS 


ANGIOMA   SERPIGINOSUM. 

Description. — Under  the  title  of  infective  angioma  or 
nevus  lupus,  Hutchinson  first  described  an  affection  charac- 
terized by  the  appearance  in  the  skin  of  minute  bright-red 
papules  having  the  appearance  of  cayenne  pepper.  The 
lesions  are  arranged  in  groups.  Gradually  increasing  in 
size,  and  spreading  by  peripheral  extension,  and  meantime, 
undergoing  central  involution,  they  eventually  form  rings 
and  circles.  New  points,  the  "satellites"  of  Hutchinson,  are 
constantly  appearing  just  a  little  beyond  the  older  patches, 
which  in  turn  pursue  a  like  evolution,  so  that  in  time  large 
areas  of  skin  are  occupied  by  gyrate  and  serpiginous 
figures.  According  to  Bowen  the  central  involuted  region 
was  not  observed  to  be  atrophic  in  the  reported  cases. 

There  are  no  subjective  symptoms.  The  progress  of  the 
disorder  is  slow,  interrupted,  however,  at  times  by  more 
rapid  advances  of  the  process  of  extension.  The  disease 
has  been  noted  on  the  upper  and  lower  extremities  and  in 
the  scapular  region  with  extension  forward  to  the  nipple. 

The  cause  of  the  disease  is  unknown ;  Darier  regards  it  as 
an  anomalous  type  of  sarcoma. 

Treatment. — Cauterization  or  excision  has  been  recom- 
mended. Crocker  advises  the  use  of  electrolysis  along  the 
extending  border  so  as  to  cause  occlusion  of  the  vessels. 
The  use  of  the  x-rays  would  naturally  suggest  itself. 


LYMPHANGIOMA  CIRCUMSCRIPTUM. 

Description. — This  is  the  only  form  of  lymphangioma 

having  especial  interest  in  a  dermatological  way. 

The  disease  first  manifests  itself,  in  the  majority  of 
cases,  in  childhood.  It  may  affect  almost  any  region  of  the 
body,  cases  having  been  reported  in  which  even  the  mucous 
membrane  was  involved.  The  lesions  which  form  the 
essential  elements  of  the  disease  are  deeply  seated  vesicles 


XERODERMA  PIGMENTOSUM  247 

with  thick  walls.  These  vesicles  are  not  disposed  singly,  but 
are  aggregated  into  patches  of  irregular  shape  from  one-half 
to  three  inches  in  diameter.  Owing  to  the  thickening  of  the 
epidermis  over  the  lesions,  the  patches  have  a  warty  look. 
The  vesicles  are  of  the  size  of  very  small  peas,  colorless 
or  pinkish,  and,  when  pricked,  emit  a  clear,  serous  fluid 
containing  lymph  corpuscles.  Over  some  of  the  vesicles 
telangiectasic  vessels  will  be  seen  coursing.  An  accidental 
rupture  of  these  may  give  to  the  contents  of  the  vesicles  a 
hemorrhagic  character.  Around  a  patch  of  closely  packed 
vesicles  will  usually  be  found  a  few  outlying  lesions,  and 
it  is  in  these  that  the  above-mentioned  peculiarities  can 
be  best  studied. 

The  course  of  the  disease  is  a  slowly  advancing  one,  with 
no  tendency  to  heal  spontaneously. 

No  cause  for  the  development  of  lymphangioma  cir- 
cumscriptum  is  known.  The  growth  is  composed  of 
flask-shaped  chambers  lying  in  the  papillary  and  deeper 
parts  of  the  cutis,  lined  with  endothelial  cells. 

Treatment. — Total  destruction  is  the  only  treatment 
which  offers  any  hope  of  success.  Caustics  have  been 
used  for  this  purpose,  but  often  the  lesions  have  again 
returned  in  the  neighborhood  or  in  the  original  area.  In 
suitable  regions  the  use  of  the  knife,  the  incision  being 
carried  quite  far  from  the  borders  of  the  patch,  will  be 
found  the  best  treatment.  In  situations  where  the  knife 
is  not  suitable,  careful  destruction  of  each  vesicle  with  the 
electrolytic  needle  or  the  galvanocautery  is  to  be  recom- 
mended. 


XERODERMA  PIGMENTOSUM. 

Description. — According  to  Kaposi,  who  first  described 
this  formidable  affection,  the  initial  lesions  consist  of 
reddish-brown  to  dark-brown  spots  from  the  size  of  a  pin's 
head  to  that  of  a  lentil,  which  appear  usually  in  the  course 
of  the  second  year  of  life,  often  preceded  by  an  erythema- 


248  VA'ir  GROWTHS 

tous  or  measles-like  eruption,  which  comes  and  goes  for  a 
time,  to  be  followed  finally  by  the  pigmentation,  which  is 
situated  upon  the  face,  neck,  arms,  and  legs,  or,  in  other 
words,  those  parts  of  the  body  that  are  more  or  less  exposed 
in  infancy.  At  first  the  freckles  as  well  as  the  intervening 
skin  are  soft  and  pliable,  but  toward  the  end  of  the  second 
and  in  the  course  of  the  third  year  punctiform  and  linear 
telangiectases  manifest  themselves  upon  and  around  the 
freckles,  which  latter  in  the  mean  time  have  become  more 
numerous.  Lentil-sized  or  larger,  white,  wrinkled,  or  des- 
quamating atrophic  spots  make  their  appearance,  which 
correspond  either  to  the  pigmentations  or  to  the  areas 
between  them.  The  skin  loses  its  elasticity,  looks  thin  and 
wrinkled,  and  is  devoid  of  glandular  orifices.  As  a  result 
of  this  atrophic  condition  considerable  disfigurement  is 
developed  in  the  form  of  erosion  of  the  lids,  xerosis  of  the 
cornea,  contraction  of  the  nasal  and  oral  cavities,  and 
deformity  of  the  ears.  The  integument  is  dry  and  rough, 
the  scalp  is  scaly,  and  pustules  and  crust-covered  ulcers 
are  to  be  noted,  especially  about  the  face. 

In  a  large  number  of  cases  certain  hypertrophic  changes 
are  to  be  noted,  sometimes  as  early  as  the  fourth  or  fifth 
up  to  the  tenth  year  of  life,  or  they  may  be  delayed  until 
the  eighteenth  or  twentieth,  or  even  so  late  as  the  fortieth 
or  fiftieth  year.  This  is  the  period  of  new  growth.  Some 
of  the  tumors  are  benign,  some  malignant.  They  generally 
originate  in  warty  patches  that  spring  from  the  pigmented 
spots. 

The  ultimate  result  in  most  of  these  formations  is 
malignancy  of  some  kind,  the  most  frequent  being  an 
epitheliomatous  degeneration.  After  the  development 
of  the  tumors  the  length  of  time  the  patient  may  survive 
is  uncertain.  Death  occurs  speedily  in  some  cases,  while 
other  unfortunates  live  many  years.  Finally,  however, 
they  succumb  to  marasmus,  or,  directly  or  indirectly, 
they  die  of  the  terrible  ravages  of  the  malady.  Of  the 
osciitial  etiology  of  xeroderma  we  have  little  knowl- 
edge. 


RHINOSCLEROMA  249 

The  disease  is  usually  met  with  in  two  or  more  members 
of  the  same  family,  and  attacks  either  sex  alike. 

Treatment. — The  treatment  is  necessarily  symptomatic. 
Internal  medication  has  proved  of  no  value. 

According  to  R.  W.  Taylor,1  who  has  had  an  unusual 
experience  with  xeroderma  pigmentosum,  especial  care 
should  be  taken  of  the  eyes,  nose,  mouth,  and  ears,  since 
in  these  situations  the  injurious  effects  of  the  disease  are 
usually  encountered.  Pigmented  warts  should  be  removed 
as  soon  as  possible,  for  fear  of  ultimate  degeneration;  and 
this  recommendation  holds  good  for  all  tumors,  large  or 
small. 

A.  W.  Bray  ton  highly  recommends  curetting  the  morbid 
growths  and  the  local  application  of  Fowler's  solution  as  a 
satisfactory  method  of  preventing  further  extension  of  the 
malignant  process. 

Jamieson,  Allen,  and  Hyde  and  Montgomery  have  re- 
ported some  encouraging  results  with  the  x-ray;  others 
have  been  less  fortunate.  As  a  prophylactic  in  the  young 
brothers  and  sisters  of  patients,  one  might  employ  negative 
phototherapy,  that  is.  the  use  of  red  clothing  and  veils,  as 
suggested  by  Pusey. 

RHINOSCLEROMA. 

Description. — This  disease,  first  described  by  Hebra  and 
Kaposi,  usually  begins  as  an  extremely  hard,  circumscribed, 
nodular  or  flattened,  somewhat  elevated,  plaque-like  growth 
about  the  alre  of  the  nose  or  the  septum.  In  rare  cases, 
however,  it  originates  in  other  sites,  as  in  the  nasopharyn- 
geal  cavity,  the  arc-lies  of  the  palate  or  the  larynx. 

It  consists  of  isolated  or  aggregated  tubercles,  of  a  normal 
to  a  dark-brown  color,  with  small  bloodvessels  ramifying 
over  the  surface.  It  is  somewhat  elastic  to  the  touch, 
bound  down  to  the  tissues,  and  of  a  hardness  comparable 

1  American  Text-book  of  Genito-urinary  Diseases,  Syphilis  and 
Diseases  of  the  Skin,  edited  by  Bangs  and  Hardaway,  p.  1014,  1899. 


250  -V/^U"  GROWTHS 

to  that  of  ivory.  The  epidermis  covering  it  is  smooth  and 
dry,  or  it  may  be  fissured  or  even  eroded,  and  covered  with 
yellowish  crusts.  The  hair  follicles  and  sebaceous  glands 
are  obliterated.  The  tumor  is,  as  a  rule,  not  painful  except 
on  pressure.  Spontaneous  involution  never  occurs. 

By  encroaching  upon  the  lumen  of  the  nose,  which  may 
be  entirely  occluded,  as  well  as  by  diminishing  the  caliber 
of  the  larynx,  respiration  may  be  embarrassed.  If  the 
obstruction  be  not  relieved  it  may  determine  a  fatal  termi- 
nation. When  removed  by  the  knife  or  caustics  the  growth 
recurs  quite  rapidly. 

The  active  cause  of  the  malady  is  a  capsulated  bacillus. 
Microscopically,  the  growth  is  a  granuloma. 

Treatment. — Permanent  removal  of  rhinoscleroma  has 
never  been  accomplished,  as  the  tumor  always  re-forms. 
Lang  obtained  a  good  result  by  the  use,  internally  and 
locally,  of  salicylic  acid.  Ten  grains  were  administered  by 
the  mouth,  three  times  a  day,  and  hypodermic  injections  of 
a  Iper  cent,  solution  were  made  into  the  growth,  while  an 
ointment  of  the  drug  was  applied  to  the  nares  on  cotton 
plugs  and  a  salicylic  acid  snuff  used.  Recently  cases  have 
been  reported  which  have  been  improved  by  radiotherapy. 
Unless  to  save  the  life  of  a  patient  from  some  threatening 
consequence,  such  as  obstruction  to  respiration,  operative 
treatment  does  not  seem  to  be  indicated.  In  such  instances 
the  knife,  curette,  or  galvanocautery  may  be  employed. 


TUBERCULOSIS  OF  THE  SKIN. 

The  invasion  of  the  skin  by  the  tubercle  bacillus  gives 
rise  to  a  variety  of  disorders,  which,  however  they  may 
differ  in  clinical  appearance,  are  due  to  the  same  cause. 
For  practical  purposes  the  tuberculoses  may  be  classified 
as  follows:  (1)  Lupus  vulgaris;  (2)  tuberculosis  verrucosa; 
(3)  tuberculosis  ulcerosa;  (4)  tuberculosis  disseminate: 
(5)  scrofuloderma. 


TUBERCULOSIS  OF  THE  SKIN  251 

Lupus  Vulgaris. l  Description.  —  Lupus  vulgaris  is 
an  exceedingly  chronic  tuberculous  disease  of  the  skin 
or  mucous  membranes  that  usually  commences  in  child- 
hood. 

The  affection  begins  as  pin-head  sized,  or  somewhat 
larger,  brownish-red,  yellow,  or  even  bright-red  spots, 
embedded  in  the  skin.  Their  color  can  be  paled  but  not 
entirely  effaced  by  pressure.  These  primary  lesions  may 
be  elevated,  depressed,  or  on  a  level  with  the  skin.  At  this 
stage  of  the  process  the  macules  may  be  quite  visible  to  the 
eye,  but  inappreciable  to  touch,  and  they  may  be  discrete 
or  closely  aggregated  into  flat  infiltrations.  These  macules 
may  also  be  detected  at  the  periphery  of  old  patches  and 
as  redevelopments  in  scar  tissue. 

Very  gradually,  translucent,  so-called  apple-jelly-like 
nodules  develop,  which  eventually,  in  months  or  years, 
form  one  or  more  dull-red,  elevated,  somewhat  scaly 
patches.  The  lupous  growth  is  of  soft  consistency,  not  hard 
like  the  nodule  of  syphilis,  and  can  readily  be  broken  down 
by  slight  pressure  with  a  probe. 

In  this  form  the  disease  continues  for  a  longer  or  shorter 
period,  but  finally  certain  retrogressive  changes  occur. 
The  lupous  tubercle  (or  lupoma)  may  undergo  resorption, 
and  leave  in  its  wake  an  atrophied,  glossy,  and  scaling  sur- 
face looking  not  unlike  a  burn,  and  usually  presenting  a 
raised  edge  made  up  of  pale  or  reddish  nodules  (lupus 
exfoliativus,  lupus  non-exedens).  In  the  majority  of  cases 
the  lupous  infiltration  breaks  down  and  ulceration  occurs 
(lupus  exulcerans).  The  ulcerations  are  seldom  painful, 
are  irregular  in  shape,  more  often  shallow  than  deep, 
present  a  well-defined  border  and  a  red,  bleeding  surface. 

1  Lupus  is  an  extremely  common  disease  on  the  continent  of 
Kurope,  relatively  frequent  in  Great  Britain,  but  in  our  experience 
ran-  in  the  United  Stales,  especially  among  the  native-born.  W  e  are 
satisfied  that  many  of  the  cases  of  so-called  lupus  recently  pul>- 
lished  in  the  journals  in  connection  with  .r-ray  treatment  wen-  cases 
of  syphilis  or,  more  generally,  epithetiooui.  In  the  larp-  dermato- 
loiiieal  clinic  of  the  Washington  University,  a  patient  with  lupus  is 
a  rarity. 


252  NEW  GROWTHS 

The  pus  secretion  is  not  profuse,  but  sufficient  to  form 
dirty,  reddish-brown  crusts.  When  healing  takes  place 
the  resulting  scars  are  generally  thick  and  distorted.  The 
course  of  lupus  is  always  exceedingly  chronic,  oftentimes 
years  elapsing  before  any  great  amount  of  surface  is  involved, 
but  eventually  its  ravages  may  be  appalling.  The  onward 
march  of  the  disease  is  by  no  means  steadily  progressive. 
As  the  result  of  various  influences,  both  local  and  con- 
stitutional, its  progress  may  be  delayed  for  awhile,  to  be 
succeeded  after  a  variable  period  by  renewed  activiy,  and 
thus  with  an  advancing  line  of  ulceration  in  one  place  and 
cicatrization  in  another,  or  a  renewal  of  the  lupus  in  parts 
already  scarred  over,  the  disorder  as  a  whole  discloses  a 
striking  clinical  picture. 

Lupus  presents  considerable  variety  in  its  clinical  expres- 
sion, due  in  part  to  the  regions  attacked,  the  constitutional 
peculiarities  of  the  sufferers  themselves,  and  the  complica- 
tions that  may  arise. 

Lupus  is  not  usually  symmetrically  disposed,  although 
it  may  become  so  accidentally.  The  disease  may  occur  in 
a  single  patch,  or  less  frequently  in  several;  on  the  other 
hand,  there  may  be  many  foci  of  disease  (lupus  dissemina- 
tus).  If  exuberant  granulations  form  in  the  lupous  patches 
it  is  known  as  lupus  hyper  trophic  us,  and  when  the  disease 
spreads  by  an  extending  border  or  the  coalescence'  of  one 
or  more  patches,  it  goes  by  the  name  of  lupus  serpiginosus. 
By  lupus  papillomatosus  is  meant  a  papillary  overgrowth, 
such  as  may  happen  on  any  ulcerated  surface,  and  in  this 
disease  is  most  often  encountered  on  the  extremities. 

Leloir  describes  a  form  of  lupus  vulgaris  under  the 
title  of  lupus  vulgaris  erythematodes,  which  we  believe  is 
relatively  common,  but  is  usually  confounded  with  lupus 
erythematosus.  It  appears  as  a  large  or  small  plaque, 
occasionally  in  one,  two,  or  three  patches,  usually  on  one 
cheek,  but  often  invading  the  nose  and  both  cheeks  in  a 
symmetrical  manner,  just  as  in  butterfly  lupus  erythem- 
atosus. 

The  face  is  the  usual  site  of  lupus,  especially  the  nose  and 


TUBERCULOSIS  OF  THE  SKIN  253 

cheeks,  as  well  as  the  ears.  The  trunk  and  extremities  are 
also  attacked,  the  hands  and  feet  not  infrequently.  It 
is  noteworthy  that  exposed  parts  are  for  the  most  part 
implicated. 

Lupus  of  the  mucous  membranes  is  often  primary,  and 
Bender  and  Finsen  have  shown  that  this  occurs  oftener 
than  has  been  generally  credited. 

Various  complications  may  arise  in  the  course  of  lupus. 
Swelling  and  suppuration  of  the  lymphatic  glands  con- 
tiguous to  the  lupous  patches  are  not  uncommon,  and 
chronic  enlargement  of  the  parotid  has  been  noted.  Ery- 
sipelas not  infrequently  supervenes,  and  sometimes  has  a 
decided  curative  effect. 

It  remains  to  add  that  there  may  be  grafted  oh  this 
already  terrible  disease  one  more  terrible,  and  that  epithe- 
lioma  often  develops  on  a  lupous  patch  or  in  the  scar  of  a 
preceding  lesion. 

In  the  great  majority  of  instances,  aside  from  the  result 
of  interference  with  local  function,  lupus  seems  to  be  with- 
out prejudicial  effect  on  the  general  health. 

Lupus  generally  begins  in  the  first  decade  of  life,  and 
rarely  commences  after  puberty,  although  there  are  some 
exceptions  to  this  rule.  For  some  unknown  reason  it 
attacks  females  more  often  than  males. 

Careful  inquiry  shows  that  a  history  of  phthisis  may 
often  be  elicited  among  other  members  of  the  family  of  a 
lupous  patient,  and  abundant  statistics  are  at  hand  to  prove 
that  secondary  tuberculous  infection  is  frequent. 

Many  carefully  recorded  cases  are  in  evidence  to  show 
that  lupus  may  result  from  direct  inoculation.  The  ba- 
cilli are  very  sparse  and  often  a  large  number  of  sections 
must  be  examined  before  their  presence  can  be  demon- 
strated. 

Diagnosis. — In  typical  cases  the  diagnosis  presents  few 
difficulties;  the  history  of  the  case,  the  disease  beginning 
early  in  life,  its  great  chronicity,  and  the  presence  of  the 
characteristic  reddish-brown,  apple-jelly,  readily  broken- 
down  tubercles  are  not  easily  misinterpreted.  There  are 


254  NEW  GROWTHS 

several  ulcerative  diseases,  however,  that  at  times  hear 
a  fairly  close  likeness  to  lupus.  The  tuberculous  and 
serpiginous  syphilides  are  especially  to  be  differentiated. 
Lupus  begins  in  early  life,  and  is  apt  to  be  definitely  local- 
ized. Syphilis  as  usually  seen  dates  from  adult  life,  and 
the  lesions  are  more  widely  dispersed.  Lupus  is  chronic 
in  its  course;  syphilis  much  more  rapid,  doing  more  harm, 
in  fact,  in  six  months,  than  lupus  in  as  many  years;  or, 
as  Payne  has  it,  lupus  is  to  syphilis  as  the  hour-hand  is  to 
the  minute-hand  of  a  clock.  Lupous  nodules  are  set  deeper 
in  the  skin,  are  reddish  brown,  and  readily  break  down; 
the  tubercles  of  syphilis  are  pinkish-red,  firmer,  and  less 
irregular  in  outline.  Lupous  tubercles  often  redevelop 
on  the  scar  left  by  the  disease;  syphilitic  tubercles  rarely 
if  at  all. 

The  ulcers  of  lupus  are  not  so  deep  and  clear  cut  as  those 
of  syphilis.  The  secretion  from  lupous  ulcers  is  scant  and 
inodorous;  from  syphilis,  purulent,  abundant,  and  offen- 
sive. The  crusts  of  lupus  are  thin  and  reddish;  the  crusts 
of  syphilis,  thick,  greenish  black,  and  may  have  the  oyster- 
shell  arrangement.  The  scars  of  lupus  are  thick,  band-like, 
and  adherent;  in  syphilis  they  are  thin,  soft,  and  movable 
(except  in  the  neighborhood  of  joints).  The  osseous 
tissues  are  not  implicated  in  lupus;  they  may  be  attacked 
in  syphilis.  Finally,  it  is  always  possible  to  apply  the  test 
of  treatment. 

Epithelioma  might  form  a  source  of  some  confusion, 
but  it  must  be  remembered  that  lupus  begins  in  early  life; 
cancer  of  the  skin  is  a  disease  first  occurring,  in  the  majority 
of  cases,  in  middle  age.  Lupus  will  probably  exhibit  several 
points  of  ulceration,  and  the  lupous  nodules  may  be  demon- 
strated; in  epithelioma  the  ulceration  starts  from  a  single 
point,  and  no  apple-jelly  lesions  are  to  be  seen.  In  lupus 
the  ulceration  extends  more  superficially  than  in  epithe- 
lioma. In  lupus  the  edges  of  the  ulcer  are  soft  and  regular, 
while  the  edges  of  the  epitheliomatous  ulcer  are  hard  and 
everted,  and  (lie  base  is  uneven  and  secretes  a  thin,  san- 
guinolent  fluid.  It  is  to  be  remembered  that  epithelioma 


TUBERCULOSIS  OF  THE  SKIN  255 

may  develop  on  a  lupus.  We  may  entertain  a  strong  pre- 
sumption in  this  country,  and  especially  among  those  born 
of  native  parents,  that  an  ulcerative  process,  say  on  the 
face,  is  not  lupus,  but  probably  epithelioma  or  syphilis, 
and  the  former  more  particularly  if  occurring  first  in  middle 
life. 

The  ulcerations  left  by  broken-down  glands  and  the 
accompanying  chronic  inflammation  of  the  skin  in  their 
neighborhood,  may  suggest  lupus,  but  the  absence  of  lupous 
nodules  and  the  presence  of  sinuses  and  enlarged  glands 
elsewhere  would  be  sufficiently  distinctive. 

Lupus  erythematosus  is  usually  symmetrical,  commences 
later  in  life,  and  is  much  more  rapid  in  its  course  than 
lupus  vulgaris;  besides,  there  are  no  ulcerations  and  no 
apple-jelly  nodules  in  the  first-named  trouble,  and  the  scales 
are  fatty  and  dip  down  into  the  sebaceous  orifices. 

Crocker  regards  tuberculin  injections  as  a  valuable  aid 
in  diagnosis.  Two  milligrams  may  be  first  tried,  and  then 
0.005  or  even  0.01  gr.,  and  the  smaller  the  dose  that  pro- 
duces local  and  general  reaction  the  more  likely  is  the 
disease  to  be  lupus  vulgaris.  A  large  dose  (0.01)  may  per- 
haps produce  slight  local  reaction  in  lupus  erythematosus, 
but  not  in  syphilis  or  epithelioma.  It  is  of  no  diagnostic 
value  in  lepra  or  scrofuloderma,  because,  according  to  the 
same  authority,  the  distinction  between  lupus  vulgaris  and 
the  latter  is  of  no  practical  importance,  while  lepra  may 
react  altogether  too  violently.  An  opsonic  determination 
(see  Part  II)  may  also  be  made  for  its  diagnostic  signifi- 
cance. 

Pressure  with  a  diascope  (a  microscope  slide  or  watch- 
crystal  will  do)  is  an  important  aid  to  diagnosis.  By 
this  procedure  it  is  possible  to  distinguish  between  an 
inflammatory  lesion  and  a  lupous  infiltration. 

Erythematoid  lupus  vulgaris  bears  a  strong  likeness  to 
lupus  erythematosus,  but  the  presence  of  lupous  nodules 
and  the  other  features  mentioned  above  should  be  sufficient 
to  prevent  mistakes. 


256  NEW  GROWTHS 

Treatment.1 — Persons  suffering  from  lupus  may  often  be 
greatly  benefited  as  to  their  local  condition  by  appropriate 
hygienic  and  general  treatment;  that  is  to  say,  while  no 
manner  of  internal  medication  will  cause  the  disappearance 
of  an  existing  infiltration,  it  may  be  made  more  amenable 
to  appropriate  local  measures,  and  to  display  less  destruc- 
tive tendency  and  less  proneness  to  relapse.  In  suitable 
cases  the  open-air  treatment  and  appropriate  diet  may  be 
ordered,  exactly  as  in  tuberculosis  of  the  lungs. 

On  the  other  hand,  cases  are  not  infrequently  encoun- 
tered in  which  there  is  no  apparent  demand  for  internal 
medication,  the  patients  possessing  good  general  health. 

The  specific  treatment  of  lupus  with  tuberculin  has  not 
come  up  to  the  expectation  of  its  early  advocates,  nor,  on 
the  other  side,  is  it  as  absolutely  valueless  as  some  have 
presumed.  Morris  says  that  a  course  of  tuberculin  injec- 
tions should  be  preliminary  to  the  treatment  of  lupus  by 
any  of  the  local  methods,  as  it  seems  to  make  the  disease 
more  amenable  to  these  measures.  Crocker  says  that  it 
will  remove  the  fibroid  thickening  that  is  often  seen  about 
the  lips  and  where  there  is  much  lax  tissue,  and  that,  more- 
over, after  as  much  lupous  tissue  has  been  removed  by 
erasion  as  possible,  it  will  dissipate  some  of  the  tissue  that 
has  escaped  destruction  from  without,  and  in  this  way 
secure  a  longer  period  of  abeyance  and  a  greater  degree  of 
permanent  cure.  M'Call  Anderson2  is  thoroughly  con- 
vinced of  the  great  value  of  tuberculin  in  lupus  and  other 
tuberculous  affections.  He  thinks  that  it  is  important  to 
observe  the  following  rules  in  carrying  out  the  treatment: 

1.  The  initial  dose  of  the  old  tuberculin,  in  the  case  of  an 
adult,  should  not  generally  exceed  |  c.c.  of  1  in  1()(K),  and 
sometimes  it  is  safer  to  begin  with  ^  c.c. 

1  The  two  best  expositions  of  the  modern  treatment  of  lupus,  the 
result  of  wide  experience,  are  those  of   Radcliffe-Crocker  in  the 
third  edition  of  his  text-book,  and  the  admirable  paper  read   by 
Malcolm  Morris  before  the  Fifth  International  Dermatological  Con- 
gress (Lancet,  October  22,  1004).    For  the  facts  and  conclusions  (lint 
follow  we  are  largely  indebted  to  these  authorities. 

2  British  Journal  of  Dermatology,  September,  1906. 


TUBERCULOSIS  OF  THE  SKIN  257 

2.  If  a  given  dose  yields  little  or  no  result,'  it  is  usually 
safer  to  give  a  second  of  the  same  strength  as  the  last, 
because  the  latter  often  acts  much  more  evenly  than  the 
former. 

3.  The  more  pronounced  the  constitutional  reaction,  the 
longer  should  the  interval  be  before  the  following  injection ; 
an  interval  of  several  days  of  apyretic  temperature  at  least. 

4.  Much  greater  care  must  be  exercised  in  increasing  the 
doses  at  the  earlier  than  during  the  later  periods  of  the 
treatment,  because  the  system  gradually  gets  acclimated  to 
it,  so  much  so,  indeed,  that,  while  an  initial  dose  of  \  c.c.  of 
1  in  1000  may  raise  the  temperature  to  103°  or  104°,  the 
final  dose — say  of  1  c.c.  of  pure  tuberculin — may  have  no 
result  at  all. 

Today,  however,  all  such  counsel  loses  much  of  its 
value  in  view  of  the  far  more  exact,  safer  and  more  effi- 
cient indications  furnished  by  the  opsonic  method.  (See 
Part  II.) 

Thiosinamine  has  been  recommended  by  H.  von  Hebra 
for  a  similar  purpose.  As  to  its  permanent  effect  upon 
the  disease,  very  little  can  be  said,  but  there  seems  to  be 
little  doubt  as  to  its  value  in  removing  cicatricial  thick- 
enings, and  thus  restoring  the  mobility  of  the  joints  and 
other  parts.  Intercurrent  attacks  of  erysipelas  have  also 
a  decided  influence  over  the  lupous  process,  as  we  can 
testify  from  experience,  but  the  best  authorities  oppose 
the  intradermic  injection  of  erysipelas  toxins  (Besnier, 
Thibierge). 

The  action  of  drugs  having  a  marked  local  reaction, 
perhaps  produces  similar  results. 

Crocker  states  that  thyroid  feeding  is  the  most  important 
adjuvant  to  surgical  or  other  local  means  that  we  possess. 
It  should  be  given  after  as  great  an  amount  as  possible  of 
tissue  has  been  removed  by  local  measures,  beginning 
with  5  gr.  of  the  desiccated  gland.  After  a  fortnight  2  gr. 
may  be  given,  and  if  the  patient  tolerates  it  the  thyroid  may 
be  given  in  doses  of  lo  gr.  per  diem.  Tabloids  are  the 
form  of  administration  preferred.  As  it  has  to  be  given  for 

17 


258  NEW  GROWTHS 

a  year  or  more,  great  care  should  be  taken  to  secure  the 
proper  dosage,  since  serious  symptoms  may  arise  at  times. 

Morris,  Pringle,  and  others  speak  highly  of  thyroid  feed- 
ing in  proper  cases.  Many  other  methods  of  treating 
lupus  constitutionally  have  been  recommended,  as,  for 
example,  injections  of  mercurial  salts. 

Whatever  may  be  the  future  of  the  internal  treatment  of 
lupus,  it  remains  true  that  local  measures  of  relief  are  para- 
mount in  importance.  The  object  of  local  treatment  is  to 
remove  the  diseased  tissue,  and,  incidentally,  to  accomplish 
this  with  as  little  deformity  as  possible.  The  measures, 
medical  and  surgical,  recommended  to  attain  these  desirable 
ends  are  almost  numberless.  In  the  choice  of  a  method  the 
surgeon  must  take  into  account  the  stage,  the  extent  and 
the  location  of  the  disease,  and  must  be  well  acquainted 
with  the  effects  that  will  follow  upon  a  particular  operation. 

In  most  instances,  an  energetic  treatment  is  demanded 
from  the  beginning.  The  local  measures  that  have  been 
recommended  from  time  to  time  are  innumerable,  but 
today,  for  the  most  part,  they  have  taken  a  place  second 
in  importance  to  that  of  the  light  treatment  of  Finsen  and 
radiotherapy.  Yet  the  older  methods  have  their  place  in 
the  therapeutics  of  lupus,  and  are  of  the  greatest  value  in 
properly  selected  cases.  These  methods  will  now  be  con- 
sidered briefly: 

Surgical  Methods. — Of  the  various  surgical  methods  of 
treating  lupus,  excision  as  practised  by  Lang  and  others 
occupies  the  front  rank.  Morris  states  that  if  carried  out 
with  thoroughness  it  gives  better  results  than  any  other 
plan  of  treatment.  The  incision  should  be  carried  well 
beyond  the  apparent  margin  of  the  affected  area  and  be  of 
a  sufficient  depth  to  remove  all  of  the  infiltration.  Whit- 
field  lays  especial  stress  on  making  it  deep  enough  to 
include  the  whole  of  the  fatty  layer.  The  wound  if  small 
may  be  closed  by  sutures,  or,  if  large,  skin-grafting  by 
Thiersch's  method  may  be  employed. 

The  operation  of  excision  is  mostly  limited  to  small 
patches,  if  on  uncovered  parts,  but  it  may  be  more  boldly 
used  in  situations  like  the  trunk  or  limbs. 


TUBERCULOSIS  OF  THE  SKIN  259 

Multiple  punctiform  scarification  is  now  but  little  used, 
either  as  an  original  procedure  or  as  supplementary  to 
erasion.  Linear  scarification,  which  consists  in  making  a 
series  of  parallel  cross  cuts  with  the  object  of  destroying 
the  nutrient  vessels  of  the  part,  is  a  far  superior  operation, 
and,  while  excessively  tedious,  is  capable  of  producing  very 
satisfactory  results,  although  relapses  are  just  as  common 
after  it  as  from  any  other  operation.  For  ulcerating  lupus 
of  the  nose  or  face  it  has  a  distinct  advantage,  as  it  is  not 
apt  to  be  followed  by  any  deformity. 

Heretofore  in  our  own  experience,  erasion  with  the  sharp 
spoon  or  dermal  curette  has  been  the  method  of  choice. 

Local  anesthesia  may  be  produced  or  the  patient  put 
under  ether.  The  hand  soon  learns  to  distinguish  between 
healthy  and  diseased  tissues,  especially  as  the  latter  come 
away  readily.  Hemorrhage  is  easily  controlled  by  pressure 
with  absorbent  cotton.  The  after-treatment  of  the  scraped 
surface  varies  with  different  operators.  Volkmann  was  in 
the  habit  of  making  multiple  punctures,  so  as  to  ensure 
complete  destruction  of  all  suspicious  points.  Crocker's 
plan,  where  there  is  much  cicatricial  tissue,  is  to  mop  on 
strong  carbolic  acid,  or,  if  the  disease  be  on  the  limbs,  to 
apply  strong  sulphuric  acid  with  a  piece  of  wood,  and  then 
neutralize  with  bicarbonate  of  soda.  Boric  lint  or  sal- 
alembroth  wool  is  then  bandaged  firmly  on  to  stay  the 
bleeding,  and  replaced  in  a  few  hours  with  wet  boric  lint 
covered  with  oiled  silk,  and  after  a  day  or  two  the  wound  is 
dressed  with  boric  acid  salve.  This  same  excellent  authority 
states  that  he  gets  better  results  where  tuberculin  has 
been  injected  as  an  after-treatment  until  the  wound  heals. 
Mr.  Morris  says  that  Sir  Joseph  Lister,  after  scraping  and 
the  cessation  of  hemorrhage,  fills  up  the  holes  with  fuming 
nitric  acid,  followed  presently  by  a  neutralizing  solution  of 
soda.  The  wound  is  then  dressed  in  the  usual  way.  T.  C. 
Fox  uses  a  cream  of  chloride  of  zinc  in  spirit  for  the  same 
ends,  and  Jamieson  goes  over  the  surface  with  a  probe  on 
which  has  boon  fused  some  chromic  acid — a  plan  of  which 
we  can  speak  highly. 


260  NEW  GROWTHS 

The  galvanocautery  is  strongly  recommended  by  Besnier 
as  a  valuable  direct  method  and,  moreover,  as  obviating 
the  possibility  of  auto-inoculation  which  may  follow  the 
bloody  operations. 

Authorities  differ  much  as  to  its  value.  Crocker  limits 
its  application  to  recurrent  nodules  and  lupus  of  the  mucous 
membranes.  Morris  declares  that  the  galvanocautery  is 
still  the  best  method  at  our  disposal  in  cases  in  which  it  is 
not  practicable  to  apply  the  Finsen  light  or  the  ovrays, 
particularly  for  small  growths. 

There  is  little  question,  however,  of  the  value  of  the 
galvanocautery  for  lupus  of  the  mucous  membranes,  and 
in  many  situations  it  is  the  treatment  of  choice  (Brocq). 

The  Paquelin  cautery  and  the  hot-air  treatment  of 
Hollaender  may  be  also  mentioned  in  this  connection. 

Medical  Methods. — In  a  small  proportion  of  cases 
soothing  remedies  are  useful  and  tend  to  promote  involu- 
tion of  the  disease.  For  non-ulcerated  surfaces  Crocker 
recommends  the  familiar  calamine  and  zinc  lotion,  and 
where  the  skin  is  unbroken  the  writers  have  seen  benefit 
from  the  unguentum  vaselini  plumbicum,  to  which  has  been 
added  about  10  per  cent,  of  aristol  or  xeroform,  preferably 
the  latter.  In  superficial  forms  of  the  disease  Brooke's 
ointment  does  excellent  service,  and  acts  much  better  than 
the  usual  mercurial  plasters : 

1$ — Hydrarg.  oleatis  (2J-5  per  cent.) .      .      .      .     5j 

Acidi  salicylici gr.  x-xv 

Ichthyolis n^xv 

Olei  lavandulse q.  s. — M. 

S. — Rub  in  with  steady  friction  ten  to  twenty  minutes,  morning 
and  evening.  The  skin  must  not  be  broken  by  the  application;  if, 
however,  this  should  occur,  the  salve  must  be  diluted  or  the  parts 
dressed  with  a  boric  acid  salve  until  it  has  re-formed. 

Such  applications,  properly  speaking,  are  merely  adju- 
vants, but  among  the  active  agents  salicylic  acid  has  been 
much  employed.  It  may  be  used,  as  suggested  by  Treves, 
made  into  a  cream  with  glycerin,  to  which  is  added  a 
small  amount  of  creosote,  or  in  the  shape  of  Inna's  plaster 
mulls.  These  plasters  may  be  renewed  once,  or,  where 


TUBERCULOSIS  OF  THE  SKIN  261 

there  is  much  exudation,  twice  daily.  They  are  made  of 
different  strengths,  and  Jamieson  recommends  that  the 
treatment  should  be  begun  with  as  strong  a  plaster  a.s  the 
part  will  bear.  The  incorporation  of  the  creosote  with  the 
salicylic  acid  materially  lessens  the  pain.  The  results 
obtained  are  often  very  satisfactory,  but,  as  in  most  other 
procedures,  new  nodules  are  apt  to  develop,  and  these 
must  be  destroyed  in  the  manner  presently  to  be  described. 

Pyrogallol  has  a  selective  action  for  lupous  tissue,  and  if 
not  used  over  too  extensive  a  surface  gives  good  results. 
It  may  be  applied  as  a  10  per  cent,  or  stronger  plaster  mull 
or  ointment,  or  as  a  saturated  solution  in  ether.  In  the 
latter  case  it  should  be  covered  over  with  traumaticine,  and 
reapplied  until  all  of  the  nodules  have  disappeared. 

Jarisch  first  recommended  a  10  per  cent,  pyrogallol 
salve  after  curetting,  to  be  followed  in  some  days  by  iodo- 
form,  and  when  healing  began  the  application  of  mercurial 
plaster  to  secure  a  good  scar.  G.  H.  Fox  uses  a  much 
stronger  salve — 25  to  50  per  cent. — as  it  shortens  the 
duration  of  the  treatment,  and  is  decided  in  his  recom- 
mendation of  this  mixed  method.  In  the  treatment  of 
small  patches  we  have  been  in  the  habit  of  using  a  thor- 
ough electrolysis,  followed  by  curetting  and  the  subsequent 
application  of  chromic  acid. 

Permanganate  of  potassium  in  10  per  cent,  strength, 
painted  on  daily  or  every  other  day,  has  been  recommended 
by  Schultz.  The  nodules  break  down  under  its  use,  and, 
it  is  claimed,  can  be  readily  wiped  away  with  absorbent 
cotton. 

Mercuric  chloride,  1  or  2  gr.  to  1  oz.,  in  solution  or 
in  ointment,  is  recommended  by  White  for  continuous 
application. 

This  list  might  be  indefinitely  extended,  but  we  believe 
that  there  is  a  well-grounded  belief  that  such  remedies  are 
too  often  followed  by  relapse  and  find  their  chief  utility 
as  auxiliaries  to  more  radical  measures. 

Among  the  more  decidedly  caustic  remedies  may  ue 
mentioned  arsenical  paste,  nitrate  of  silver  in  stick  or  solu- 


262  NEW  GROWTHS 

tion,  and  lactic  acid,  the  latter  especially  for  small  ulcera- 
tions  and  lesions  of  the  mucous  membranes.  Whitfield 
considers  zinc  chloride,  freshly  ground  up  with  glycerin 
and  water  into  a  paste,  so  far  superior  to  all  other  agents 
that  he  uses  it  alone. 

Freezing  with  ethyl  chloride  has  been  employed.  Pusey 
suggests  solidified  carbon  dioxide  or  liquid  air  for  the 
same  purpose  in  dealing  with  discrete  nodules  or  small 
patches. 

Recurrent  nodules  may  be  destroyed  by  electrolysis,  as 
recommended  by  one  of  us1  many  years  since,  by  the  dental 
burr  of  Fox,  the  double  screw  of  Morris,  or  by  boring  in 
with  a  toothpick  dipped  in  acid  nitrate  of  mercury,  or  by 
the  thermocautery.  The  "thorn  treatment"  of  Unna 
consists  in  applying  the  liquor  antimonii  chloridi  by  means 
of  the  thorns  of  the  gooseberry  bush,  which  are  thrust  into 
the  nodules  and  then  cut  off  and  allowed  to  remain  in 
position  until  they  come  away. 

The  Finsen  Light. — What  is  known  as  the  Finsen  treat- 
ment consists  in  concentrating  the  chemical  rays  of  light 
on  the  diseased  area  and  cutting  off  the  heat  rays  by  suitable 
means  as  far  as  practicable.  At  the  same  time  the  parts 
to  be  acted  upon  must  be  rendered  bloodless  by  deep 
pressure.  Cure  is  thought  to  be  due  to  the  bactericidal 
effect  of  the  chemical  rays. 

The  technique  of  the  procedure  has  been  considered 
elsewhere  (see  Phototherapy,  Part  II) ;  in  this  place  the 
general  results  of  the  light  treatment  will  be  presented. 
Briefly  stated,  it  is  claimed  that  phototherapy  gives  more 
satisfactory  results  than  any  other  form  of  treatment,  espe- 
cially in  dry  and  non-exedent  cases,  and  that  the  cosmetic 
effects  are  greatly  superior.  Statistics  would  seem  to  have 
proved  the  first  contention,  and  personal  observation  the 
second.  It  does  not  follow,  however,  that  the  light  treat- 
ment is  equally  applicable  to  all  cases.  It  is  contra-indi- 
cated in  long-standing  cases  that  have  been  much  treated, 

1  Hardaway. 


TUBERCULOSIS  OF  THE  SKIN  263 

and  where  there  is  much  scar  tissue  present.  It  is  not 
applicable  to  the  mucous  membranes,  nor  to  situations 
where  it  is  difficult  to  press  out  the  blood  from  the  tissues. 
It  is  often  necessary  to  combine  other  forms  of  treatment 
with  the  use  of  the  light,  as,  for  example,  applications  of 
pyrogallol,  erasion,  and  the  x-rays.  The  chief  objections  to 
phototherapy  are  the  time  required — many  months  in  ex- 
tensive cases — the  cost,  directly  and  indirectly,  and  in  this 
country  especially,  where  lupus  is  uncommon,  the  difficulty 
of  securing  the  true  Finsen  treatment  in  all  its  rigor. 

Statistics  from  the  Finsen  Institute  for  a  period  of  seven 
years  show  737  cases  treated:  412  cured,  192  nearly  cured, 
and  91  others  progressing  favorably.  Of  the  412  "cured," 
124  had  remained  free  from  recurrence  during  periods  of 
observation  ranging  from  two  to  six  years.  Only  42,  or 
6  per  cent,  of  the  whole,  gave  unfavorable  results.  At  the 
Hopital  Saint-Louis,  with  an  inferior  lamp,  30  cases  gave 
11  complete  and  12  partial  cures.  At  the  London  Hos- 
pital, up  to  1903,  there  were  treated  398  cases,  of  which 
149  were  discharged  as  cured. 

G.  H.  Graham  believes  that  the  injection  of  a  fluorescent 
body,  such  as  esculin,  enhances  the  action  of  the  light. 
Forchhammer  failed  in  23  cases  in  which  he  used  a  1  to 
1000  solution  of  erythrosin  subcutaneously.  Tappeiner 
paints  on  a  0.01  to  0.1  per  cent,  solution  of  eosin  before 
exposure. 

Exposures  of  from  three-quarters  of  an  hour  to  an 
hour  and  one-half  with  a  Finsen  or  Finsen-Reyn  lamp,  are 
repeated  once  or  twice,  allowing  intervals  of  about  ten 
days  for  subsidence  of  the  reaction,  which  varies  from  an 
erythema  to  a  vesicular  or  bullous  dermatitis.  Daily 
scaiiccs  are  given  in  extensive  cases,  a  different  area  being 
treated  each  day.  In  superficial  cases  the  London  or  the 
iron-electrode  lamp  may  be  used  at  first,  to  be  followed 
by  the  Finsen  or  Finsen-Reyn  lamp  for  the  deeper-lying 
parts. 

The  x-rays  should  not  be  used  to  supplant  other  methods, 
but  as  an  adjuvant  to  them.  Few  cases  can  be  brought  to 


264  NEW  GROWTHS 

a  real  cure  by  the  use  of  the  rays  alone,  and  even  in  these 
much  time  can  be  saved  by  an  intelligent  use  of  the  older 
methods.  In  certain  forms  of  the  disease,  as  for  instance 
in  small  patches  of  non-exedent  lesions  without  much 
cicatrization,  erasion,  cauterization,  or  electrolysis  are  to 
be  preferred.  The  x-ray  is  best  adapted  to  hypertrophied 
and  sclerosed  lesions,  to  ulcerated  cases  with  deep  scarring, 
to  isolated  scattered  nodules,  and  to  mucous  surfaces. 

Scholtz  believes  that  ulcerated  cases  should  be  first 
treated  by  pyrogallic  ointment  in  increasing  strength,  to  be 
followed  by  irradiation.  Deep  cases  should  be  curetted 
and  cauterized  with  hot-air  at  first,  then  the  x-rays  should 
be  used  together  with  a  pyrogallic  ointment,  and  lastly 
light  rays. 

^Y-rays  present  the  following  advantages  over  photo- 
therapy: Compression  of  the  surface,  a  painful  procedure, 
is  unnecessary;  treatments  are  less  frequent  and  less 
prolonged;  a  larger  surface  may  be  attacked  at  one  sitting; 
the  x-rays  being  more  penetrating,  and  deeper  portions 
can  be  attacked,  whereas  a  cicatricial  layer  will  arrest  the 
chemical  rays. 

On  the  other  hand,  radiotherapy  is  more  dangerous  to 
the  integrity  of  the  skin,  and  the  statistics  are  not  quite  so 
good  as  those  of  phototherapy  at  its  best.  Morris  and 
Dore,  Harrison  and  Wills,  of  Bristol,  and  Schamberg 
prefer  phototherapy  to  the  x-rays,  except  on  mucous  sur- 
faces. This  method,  like  all  others,  shows  a  certain  pro- 
portion of  recurrences. 

Technique. — The  older  method  was  to  set  up  a  violent 
inflammation  and  thus  secure  necrosis  of  lupous  nodules. 
Most  operators  today  are  content  to  excite  a  mild  erythema 
with  increased  leukocytosis. 

Albers-Schonberg  commences  with  ten-minute  sittings, 
two  or  three  times  a  week,  and  gradually  increases  the 
time. 

Williams  pursues  a  similar  plan.  Scholtz,  while  admit- 
ting that  this  method  may  be  best  adapted  to  some  cases, 
here  as  elsewhere  prefers  more  heroic  treatment.  He 


TUBERCULOSIS  OF  THE  SKIN  265 

indeed  deprecates  the  production  of  deep  destructions, 
but  says:  "We  do  not  understand  why  operators  are  so 
anxious  to  avoid  superficial  ulceration  of  the  skin.  Intense 
irradiations  are  most  efficacious  in  severe  forms  of  lupus 
and  many  other  diseases." 

Kienbock  gives  a  "normal"  dose  of  3  or  4  H.  at  intervals 
of  one  or  two  months  in  hypertrophic  cases,  later  employ- 
ing phototherapy.  In  ulcerative  cases  he  prefers  photo- 
therapy from  the  first,  as  does  Jamieson.  Holzknecht 
precedes  the  lamp  by  the  tube. 

Pusey's  brilliant  successes  in  this  disease  have  been  won 
by  the  patient  use  of  mild  exposures  frequently  repeated. 
One  of  us  secured  a  cure  after  two  years'  treatment  by 
weak,  frequently  repeated  doses,  in  a  case  which  had  existed 
for  fifty-seven  years,  deeply  ravaging  the  whole  face.  A 
burn  being  (undesignedly)  produced  on  one  cheek,  a 
papillary  epithelioma  developed  at  the  exact  centre  of  the 
burned  area.  This  was  excised  and  has  not  returned. 
McLeod  and  Da  Costa  have  had  similar  experiences. 

We  do  not  know  that  we  can  do  better  in  this  connec- 
tion than  to  quote  literally  from  Malcolm  Morris'  recent 
paper1  on  the  treatment  of  lupus  during  the  last  twenty-five 
years. 

For  purposes  of  treatment,  by  the  methods  under  con- 
sideration, Morris  divides  lupus  into  five  classes  as  follows: 

1.  "Cases  of  Small  Extent  in  which  No  Previous  Treatment 
has  been  Employed. — In  such  cases  Finsen's  method  is  the 
best,  as  it  leaves  little  scar  and  gives  as  permanent  results 
as  severer  methods.    The  x-ray  is  also  useful  under  these 
circumstances,  but  the  time  required  is  relatively  longer 
owing  to   the   difficulty  of  eliminating   residual   nodules, 
and  it  is  possible  that  a  telangiectatic  scar  may  follow  the 
application. 

2.  "Cases  of  Small  Extent  with  a  Dense  Fibrous  Cicatrix 
due  to  Previous  Treatment. — Both  the  Finsen  method  and 
the  x-rays  are  tedious  if  applied  in  the  usual  manner,  but 

1  Lancet,  October  22,  1904.  Read  before  the  Fifth  International 
Dermatological  Congress. 


266  NEW  GROWTHS 

repeated  applications  to  the  same  area,  without  allowing 
healing  to  take  place  between  the  applications,  are  more 
efficacious,  although  more  painful. 

3.  "Cases  of  Large  Extent  in  which  Lupus  is  Relatively 
Superficial  or  the  Nodules  more  or  less  Discrete. — In  cases  of 
this  kind  it  is  better  to  begin  with  the  x-rays  and  to  finish 
with  the  light  rays.     More  rapid  results  are  obtained  by 
the  concurrent  use  of  Rontgen    and    Finsen  rays.     The 
whole  area  should  be  exposed  to  the  x-rays  and  the  edge 
treated  by  light. 

4.  "Gases  of  Large  Extent  in  which  there  is  a  Dense  Mass 
of  Lupous  Infiltration  and  Fibrous  Tissue. — Here  neither  the 
light  nor  the  x-rays  make  much  impression.     Probably 
vigorous  preliminary  surgical  measures  such  as  excision  or 
scraping,  followed  as  soon  after  as  possible  by  the  x-rays 
and  again  by  the  Finsen  light  if  necessary,  would  con- 
siderably reduce  the  duration  of  treatment  and  give  better 
results  than  those  obtained  from  the  x-rays  or  the  Finsen 
light  alone. 

5.  "In  Lupus  of  Mucous  Membranes  great  initial  improve- 
ment follows  the  use  of  the  x-rays,  but  relapses  are  fre- 
quent.   In  the  upper  parts  of  the  nasal  fossae  radium  might 
be  of  use.    I  have  had  very  little  or  no  experience  of  this 
agent.    Galvanocautery  is  of  service  in  such  cases. 

"To  sum  up,  the  combination  of  Finsen's  methods  with 
the  x-rays,  reinforced  when  necessary  by  the  use  of  pyro- 
gallic,  salicylic,  or  carbolic  acid  or  other  caustic  applica- 
tions, has,  in  my  experience,  given  good  results  in  cases  of 
lupus  in  which  the  disease  is  not  very  extensive  and  does 
not  spread  too  rapidly  to  be  overtaken  by  treatment. 
Vigilant  supervision  is  necessary  to  detect  any  appearance 
and  to  destroy  fresh  nodules  in  the  earliest  stage  of  their 
development." 

Radium. — This  agent  has  been  but  little  employed  in 
lupus  owing  to  certain  practical  difficulties.  Norman 
Walker  states  that  he  can  speak  highly  of  its  value  in  small 
patches  of  lupus  of  the  skin,  and  more  particularly  in  lupus 
of  thejpalate. 


TUBERCULOSIS  OF  THE  SKIN  267 

Prognosis. — A  very  guarded  opinion  must  be  expressed 
in  regard  to  the  prognosis  of  lupus,  for  under  any  form  of 
treatment  now  known  relapses  of  the  process  are  the  rule. 
Naturally,  also,  the  various  circumstances  of  age,  location, 
acuteness,  extent,  and  duration  must  be  taken  into  account. 
The  results  of  treatment  are  more  satisfactory  in  elderly 
people  than  in  the  young,  and  limited  superficial  areas  of 
the  disease  may  be  permanently  cured.  Although  lupus 
is  exceedingly  chronic  in  its  course,  often  lasting  twenty 
or  thirty  years,  it  is  rarely  inimical  to  the  general  health, 
certainly  in  this  country,  but  it  would  seem  from  foreign 
statistics  that  general  tuberculous  infection  is  more  fre- 
quent than  was  formerly  supposed. 

Tuberculosis  Verrucosa.  Description. — The  anatomi- 
cal wart  or  verruca  necrogenica  commences  as  a  small,  flat 
infiltration  on  the  knuckles  or  between  the  fingers,  and 
soon  becomes  pustular.  Finally,  the  surface  becomes 
irregular  arid  warty  and  presents  the  type  of  a  papilloma. 
It  is  not  uncommon  on  the  hands  of  those  engaged  about 
the  dissecting  room  or  in  making  postmortem  exami- 
nations. The  condition  is  usually  benign,  sometimes  un- 
dergoing spontaneous  cure,  but  occasionally  lymphatic 
involvement  and  constitutional  infection  may  occur. 

Under  the  name  of  tuberculosis  verrucosa  cutis  an  allied 
disorder  has  been  described,  due  to  infection  with  tuber- 
culous matter. 

It  is  rare  on  the  palms,  but  is  met  with  generally  on  the 
backs  of  the  hands  and  the  interdigital  spaces,  just  as  in  the 
anatomical  tubercle.  It  occurs  in  large  and  small  warty 
patches,  round,  oval,  or  serpiginous.  These  patches  extend 
peripherally,  and  are  surrounded  by  a  bright  erythematous 
areola,  within  which  may  be  detected  a  zone  of  small 
scattered  pustules  seated  on  a  brownish  or  livid  infiltration. 
The  middle  of  the  patch  is  made  up  of  uneven  and  warty 
growths,  which  are  covered  with  crusts,  and,  as  is  usual 
with  such  formations,  pus  may  be  made  to  well  up  from 
between  the  papillomata.  The  affection  disappears  by 
flattening  of  the  central  verruca?  and  drying  up  of  tlic 


268  NEW  GROWTHS 

pustules;  a  pliant,  thin,  sieve-like  scar  results.  Tubercle 
bacilli  have  been  demonstrated  in  the  granulation  tissue 
and  in  the  giant  and  epithelial  cells  of  the  caseous  nodules 

Other  forms  of  this  type  of  tuberculosis  have  since  been 
recorded. 

Treatment. — The  treatment  is  essentially  the  same  as 
that  for  lupus  vulgaris.  Erasion  with  the  curette  followed 
by  the  thermo-  or  galvanocautery  is  usually  effective. 

Ullmann  believes  that  the  x-rays  yield  better  results 
in  verruca  necrogenica  than  in  lupus.  Zeisler,  Campbell, 
and  others  have  met  with  success  in  its  use.  Phototherapy 
has  been  commended.  Gottheil  gives  it  the  preference. 

Tuberculosis  Ulcerosa.  Description. — This  condition, 
also  called  tuberculosis  cutis  vera,  occurs  on  persons  who  are 
the  subjects  of  general  tuberculosis.  It  has  its  origin  at 
the  mucocutaneous  outlets,  namely,  the  lips,  anus,  vulva, 
etc.,  whence  it  spreads  to  the  contiguous  skin.  The  lesions 
are  painless  and  occur  in  the  form  of  shallow,  isolated 
ulcers  with  slightly  infiltrated  edges,  and  reddish-yellow 
floors  covered  with  a  thin  secretion. 

Treatment. — The  treatment  is  that  of  the  general  disease 
upon  which  the  ulcers  depend. 

Locally,  cleansing  lotions  and  gently  stimulating  appli- 
cations are  of  temporary  value.  Lactic  acid,  usually 
somewhat  diluted,  is  a  good  application. 

The  curette  and  galvanocautery  may  occasionally  be  em- 
ployed. Gottheil  considers  phototherapy  the  best  treatment. 

Tuberculosis  Disseminata.  Description. — Various  cu- 
taneous lesions,  macular,  papular,  vesicular,  ulcerative, 
etc.,  acute  or  subacute,  have  been  observed  in  children 
suffering  from  scrofulosis;  and  there  is  another  form  of 
disseminated  tul>erculosis  of  the  skin,  known  as  exanthe- 
maticmiliary  tuberculosis,  which  follows  in  the  wake  of  the 
eruptive  fevers  of  childhood  and  is  due  to  the  same  general 
condition. 

Treatment. — The  treatment  of  these  cutaneous  tuber- 
culoses is  the  treatment  of  the  condition  upon  which  they 
depend. 


TUBERCULOSIS  OF  THE  SKIN  269 

Scrofuloderma.  Description.  —  The  most  frequently 
encountered  form  of  scrofuloderma  has  its  origin  in  the 
lymphatic  glands  in  the  neck,  and  more  rarely  in  the 
axillary  and  inguinal  regions.  The  glands  may  be  felt 
under  the  skin  as  numerous,  rather  firm  and  movable 
bodies  which  grow  but  slowly  and  are  always  indolent. 
Sometimes  several  glands  attain  a  considerable  size — one 
inch  or  more — or  an  agglomeration  of  glands  may  be 
detected,  but,  it  is  said,  without  becoming  fused  or  matted 
together  (Eve).  The  glands  may  remain  as  indolent  nodules 
for  an  indefinite  period,  or  they  may  undergo  resolution 
without  suppuration. 

Suppuration  is,  however,  the  usual  termination  of  the 
process,  the  overlying  skin  meanwhile  becoming  thinned 
and  of  a  violaceous  color.  When  the  abscess  bursts  it 
emits  a  thin,  curdy  pus,  more  or  less  mixed  with  blood. 
Sinuses  and  fistulous  tracts  form;  the  skin  is  undermined 
and  perforated,  and  strumous  ulcers  are  developed. 

The  cicatrices  that  result  from  the  healing  process  are 
bound  down  to  the  underlying  tissues,  ridged  and  knotty 
and  often  hypertrophic.  The  course  of  the  affection  is 
exceedingly  slow,  ulceration  and  repair  going  on  hand  in 
hand  for  months. 

There  is  also  a  variety  of  scrofuloderma — the  so-called 
scrofulous  gumma — which  begins  in  the  form  of  bean- 
sized  nodules  that  gradually  enlarge  to  hazel-  or  walnut- 
sized  tumors,  and  are  unaccompanied  by  subjective 
symptoms.  They  may  or  may  not  suppurate;  in  the 
former  case  there  will  be  present  typical  strumous  ulcera- 
tion, or,  on  the  other  hand,  their  contents  may  be  resorbed. 
These  gummata  may  also  occur  along  the  course  of  the 
lymphatics  of  a  limb  (Hallopeau). 

Scrofuloderma  is  observed  in  both  sexes.  It  is  very  com- 
mon among  negroes  in  this  country.  Scrofula  is  a  disease 
of  early  life,  although  it  may  occur  in  aged  people. 

Pustular  Scrofulides. — Duhring  describes  a  cutaneous 
manifestation  which  consists  of  one  or  more  large,  flat 
pustules  seated  upon  an  inflamed  or  violaceous  base. 


270  NEW  GROWTHS 

The  crust  forms  slowly,  is  thin  and  flat,  and  of  a  brownish 
color.  The  ulceration  beneath  has  the  "  peculiar  scrofulous 
character,"  although  the  scars  are  soft,  flat,  and  superficial. 
The  same  observer  calls  attention  to  another  variety  of 
disease,  observed  in  scrofulous  subjects,  which  declares 
itself  in  the  shape  of  small  pin-head  to  pea-sized,  dis- 
seminated, yellowish  papulopustules,  upon  a  base  similar 
in  character  to  that  found  with  the  large  pustular  lesion 
just  mentioned.  The  lesions  occur  for  the  most  part  on 
the  face  and  extremities,  and  leave  punched-out,  variola- 
like  scars.  The  process  may  continue  for  years. 

Associated  with  the  ordinary  expressions  of  the  scrofu- 
lodermata  may  be  found  lupus  vulgaris,  tuberculous 
dactylitis,  and  certain  forms  of  cutaneous  disease,  as  lichen 
scrofulosus,  various  pustular  eruptions  and  the  erythema 
induratum  of  Bazin. 

Treatment. — The  constitutional  treatment  of  scrofulo- 
dermata  should  be  directed  to  the  improvement,  in  every 
way  possible,  of  the  patient's  nutrition. 

Cod-liver  oil,  malt,  iron,  especially  the  syrup  of  the 
iodide,  the  hypophosphites,  and  the  lactophosphate  of 
lime  are  all  valuable  remedies.  Arsenic  is  praised  by 
Buchner  and  Eve.  Good,  nourishing  food,  appropriate 
exercise,  well-ventilated  sleeping  apartments,  residence  in 
the  country  or  at  the  seashore,  together  with  all  other 
suitable  hygienic  measures,  are  of  the  utmost  importance. 

Ringer,  Crocker,  and  others  advise  sulphide  of  calcium 
for  the  multiple  cold  abscesses.  Crocker  especially  recom- 
mends chaulmoogra  oil  in  the  form  of  an  emulsion  in  from 
10-  to  30-  minim  doses,  and  an  ointment  externally.  ( ! .  II. 
Fox  has  seen  good  results  from  the  internal  use  of  iodide  of 
starch  in  strumous  subjects. 

Treves  very  wisely  states  that  in  treating  any  case  of 
gland  disease  the  first  rule  is  to  remove  all  sources  of 
peripheral  irritation,  viz.,  disorders  of  the  eye,  mouth, 
pharynx,  or  skin.  To  promote  resolution  this  authority 
highly  recommends  the  unguentum  plumbi  iodidi. 

The   local  treatment  is   mostly  surgical.     Broken-down 


LICHEN  SCROFULOSUS,  OR  SCROFULOSORUM     271 

glands,  sinuses,  and  ulcers  should  be  thoroughly  curetted, 
touched  with  pure  carbolic  or  lactic  acid,  and  afterward 
dressed  with  iodoform.  Treves  uses  a  fine  point  of  the 
thermocautery,  which  is  thrust  through  the  skin  into  the 
substance  of  the  gland,  and  is  passed  in  several  directions 
through  the  gland  tissue  before  it  is  withdrawn.  Excision 
gives  good  results  in  suitable  cases;  that  is,  in  those  in- 
stances in  which  there  are  present  two  or  three  movable 
and  superficially  seated  glands,  or  in  chronic  circumscribed 
enlargements  that  have  resisted  other  methods  of  treatment 
(Eve). 

Zeisler,  Bishop,  Williams,  and  others  have  obtained  as 
good  results  by  the  a>rays  in  the  treatment  of  this  disease 
as  in  lupus.  The  Finsen  light  has  been  recommended. 

LICHEN  SCROFULOSUS,  OR  SCROFULOSORUM. 

Description. — This  disorder  is  exceedingly  rare  in  this 
country.  The  following  description  is  condensed  from 
Kaposi's  text-book :  The  eruption  is  made  up  of  pale-red  to 
brownish  or  livid-red  papules,  millet-seed  to  pin-head  sized, 
arranged  in  groups  and  patches  varying  in  circumference 
from  a  dime  to  a  dollar,  and  also  here  and  there  presenting 
circles  and  curves.  The  lesions  are  capped  with  a  small 
scale  and  more  rarely  with  a  minute  pustule.  There  is  but 
slight  pruritus.  They  remain  for  years  almost  unchanged, 
then  finally  undergo  involution  with  slight  desquamation 
and  fading  color,  and  show  no  evidence  of  their  previous 
existence.  The  usual  seat  of  the  eruption  is  the  trunk,  back, 
and  abdomen.  In  the  beginning  the  patches  are  isolated, 
but  later  adjacent  groups  may  coalesce  and  give  the  appear- 
ance of  a  diffuse  disease,  at  whose  borders  the  skin  is  of  a 
dirty-brown  color  and  covered  with  thin,  detachable  scales. 
But  even  under  these  latter  conditions  the  original  grouping 
and  lesional  features  may  be  demonstrated.  About  the 
openings  of  the  sebaceous  glands  there  are  also,  as  already 
stated,  papules  arranged  in  circular  lines.  Rarely,  through 
involution  and  evolution  of  the  papules,  serpiginous  forms 


272  NEW  GROWTHS 

may  be  observed;  after  months  similar  lesions  appear  on 
the  flexor  sides  of  the  upper  and  lower  extremities  and  also 
on  the  face.  In  some  cases  eczematous  and  pustular 
eruptions  may  arise  as  complications.  Nodules  and  pus- 
tules surrounded  by  a  hemorrhagic  areola  may  appear  on 
the  lower  limbs.  Some  90  per  cent,  of  these  patients 
suffer  from  glandular  swellings  and  other  scrofulous  mani- 
festations. The  majority  of  the  cases  occur  at  or  before 
puberty.  While  the  histological  architecture  of  these 
lesions,  according  to  McLeod,  "does  not  do  more  than 
suggest  a  form  of  tuberculosis,"  yet  several  observers, 
among  whom  Jacobi  and  Pellizari,  have  demonstrated  in 
them  the  presence  of  tubercle  bacilli,  and  made  successful 
inoculations. 

The  disorder  should  be  differentiated  from  papular 
eczema  and  the  small  papular  syphilide. 

Treatment. — The  treatment  consists  in  the  internal  use 
of  cod-liver  oil,  with  or  without  iodide,  and  the  inunction 
several  times  daily  of  cod-liver  oil.  Under  this  manage- 
ment improvement  is  rapid. 

Crocker  states  that  inunctions  of  plain  vaselin,  or  vaselin 
with  5  gr.  of  thymol  to  1  oz.,  give  as  good  results  as  the 
more  disagreeable  cod-liver  oil  applications. 


ERYTHEMA  INDURATUM. 

Description. — Under  the  name  of  erytheme  indure  des 
serofuleux,  Bazin  originally  called  attention  to  a  disorder 
that  is  most  frequently  seen  in  delicate  young  girls,  or 
women  under  thirty  years  of  age.  The  disease  first  shows 
itself  in  the  shape  of  several  hard  indurations  of  the  skin, 
which  can  be  more  readily  felt  than  seen.  These  nodules 
are  generally  found  on  the  legs,  and  especially  just  below 
the  bulge  of  the  calf;  they  have,  however,  been  also 
observed  over  the  leg  generally  and  on  the  thigh.  AVhen  a 
number  of  lesions  are  present  they  coalesce  into  brawny 
patches,  and  in  the  course  of  time  the  skin  covering  the 


BLASTOMYCOSIS  273 

infiltration  becomes  red  and  then  violaceous.  Involution 
may  take  place  after  a  considerable  time,  or  else  the  indura- 
tion may  slough  out,  leaving  indolent  ulcers  that  are  slow 
in  healing.  There  are  no  symptoms  of  acute  constitutional 
disturbance,  but  there  is  occasionally  some  pain  in  the 
limbs.  Its  chronicity,  the  small  number  of  nodules  present 
at  first,  and  the  freedom  from  systemic  disturbance,  dis- 
tinguish this  disorder  from  erythema  nodosum.  The 
disease  is  most  often  mistaken  for  syphilitic  gummata, 
but  the  absence  of  specific  history  and  concomitant  symp- 
toms, the  evolution  of  the  disease,  and,  above  all,  the 
failure  of  antisyphilitic  treatment,  usually  suffice  for  the 
diagnosis.  The  etiology  of  the  disease  is  obscure.  Ex- 
perimental inoculation  has  yielded  contradictory  results, 
so  that  while  it  is  apparently  proved  that  some  cases  are 
due  to  the  presence  of  tubercle  bacilli,  others  may  be 
caused  by  the  toxin  alone. 

Treatment. — The  essential  features  of  the  treatment  are 
rest  in  bed,  proper  bandaging,  and  the  administration  of 
cod-liver  oil  or  malt  extract  with  the  hypophosphites. 
The  ulcers  may  be  dusted  with  aristol  or  xeroform,  or 
other  similar  preparations.  Stelwagon  advises  that  the 
whole  surface  of  the  leg  should  be  washed  with  a  saturated 
boric  acid  lotion  containing  3  to  10  gr.  of  resorcin  to  1 
oz.,  and  when  patients  are  not  in  a  position  to  secure 
absolute  rest,  he  puts  on  a  zinc  and  ichthyol  gelatin  dress- 
ing, leaving  windows  over  each  ulcer  as  in  varicose  eczema. 
Hutchinson  recommends  an  ointment  of  5  gr.  of  bisulphuret 
of  mercury  to  1  oz.  of  benzoated  lard. 


BLASTOMYCOSIS. 

Description. — Blastomycosis  is  a  rare,  chronic,  infec- 
tious disease  due  to  a  yeast  fungus,  the  blastomyces,  and 
is  characterized  by  verrucous,  granulating  patches  studded 
with  minute  abscesses. 

The  disease  begins  as  a  papule  or  papulopustule  which 
18 


274  NEW  GROWTHS 

is  soon  covered  by  a  crust.  As  the  lesion  slowly  enlarges, 
it  takes  on  the  appearance  characteristic  of  the  disease. 
It  requires  several  months  to  attain  to  a  diameter  of  one 
inch,  often  after  years  growing  to  the  size  of  a  silver  dollar 
or  the  palm,  and  in  rare  instances  much  larger,  and  to  an 
elevation  of  from  one-eighth  to  three-eighths  of  an  inch. 
In  about  one-half  of  the  cases  additional  foci  appear.  Occa- 
sionally the  lesion  heals  spontaneously.  The  resultant  scar, 
except  in  cases  that  have  been  deeply  cauterized,  is  smooth 
and  not  especially  disfiguring.  Pain  is  slight  or  absent  and 
the  general  health,  as  a  rule,  unimpaired,  although  three 
cases  have  succumbed  to  systemic  blastomycetic  infection. 

The  disease  more  often  appears  on  the  face,  a  patch  imme- 
diately below  the  orbit  and  involving  the  lower  lid  being 
especially  characteristic.  The  cheek,  temple,  and  lips  have 
been  invaded.  Other  regions,  in  the  order  of  frequency, 
are  the  hand,  leg,  thigh,  foot,  scrotum,  and  upper  part 
of  the  back. 

Hyde  gives  the  following  description:  "There  was 
always  the  slightly  elevated  border,  well-defined,  sharply 
raised,  composed  of  minute  verruciform  elevations  com- 
mingled with  small,  yellow  points  from  which  pus  could  be 
expressed.  On  the  side  of  the  sound  skin  there  was  always 
the  bluish-red,  sloping  border,  close  inspection  of  which 
revealed  pin-point-sized  abscesses  not  very  thickly  set, 
and  on  the  inner  or  morbid  side  of  the  enclosing  wall  was 
either  a  moist,  granulating  surface,  or  a  partly  cicatrized, 
reddish  disk,  with  here  and  there  projecting  areas  made 
up  of  verrucous  elevations,  similar  to  those  recognized  in 
the  surrounding  ridge." 

Diagnosis. — The  papillomatous  lesions  of  this  disease 
bear  some  resemblance  to  fungating  epithelioma  or 
syphilis,  but  differ  from  these  by  the  minute,  warty  points, 
interspersed  with  miliary  pus  collections,  along  the  well- 
defined,  sharp  border,  and  the  bluish-red,  sloping  zone 
beyond.  The  greatest  resemblance,  however,  is  to  tuber- 
culosis verrucosa. 

Hyde  gives  the  following  points  of  difference:     "The 


LUPUS  ERYTHEMATOSUS  275 

latter  is  usually  single,  while  blastomycetic  dermatitis  at 
one  time  or  another  exhibits  multiple  invasions.  Tuber- 
culosis verrucosa  rarely  occurs  on  the  face,  which  is  the 
site  of  election  in  the  disease  under  consideration.  The 
potassium  iodide  has  a  marked  effect  on  blastomycetic 
lesions,  but  not  in  the  other  disease."  In  some  cases  the 
microscope  alone  can  decide.  To  the  contents  of  one  of 
the  miliary  abscesses,  or  a  bit  of  teased  tissue,  a  drop  of  a 
20  or  30  per  cent,  solution  of  potassic  hydrate  is  added. 
In  from  ten  minutes  to  an  hour  the  pus  cells  or  tissue  will 
have  disintegrated  and  the  spherical-budding  organisms 
will  be  easily  visible. 

Prognosis. — Most  cases  do  well  under  the  treatment 
outlined  above,  although  recurrences  are  common  even 
in  apparently  good  scars.  Fatal,  systemic  infection  has 
been  observed,  as  noted  above. 

Treatment.  Internal. — Bevan  introduced  the  use  of 
potassium  iodide  internally.  This  agent  brings  about 
marked  improvement,  and  in  rare  instances  has  wrought 
a  cure,  although  daily  doses  of  from  200  to  500  gr.  are 
sometimes  necessary  before  the  change  is  appreciable. 
In  most  cases  there  is  for  a  time  rapid  amelioration  under 
the  iodide,  but  isolated  patches  remain,  and  as  soon  as 
the  drug  is  discontinued  the  disease  resumes  its  former 
activity.  Copper  sulphate  has  recently  been  suggested, 
given  in  the  doses  of  J  gr.  increased  to  1  gr.,  three  times  a 
day. 

Local. — Hyde  recommends  cleansing,  antiseptic  lotions, 
or  dry  dressings.  Complete  excision  when  practised  has 
been  followed  by  permanent  cure,  while  curetting  has 
only  attained  temporary  results.  Hyde,  Pusey,  Fischkin, 
Williams,  of  Boston,  and  Heidingsfeld  have  had  good 
results  from  a  combination  of  potassium  iodide  and  the 
ie-rays.  . 

LUPUS  ERYTHEMATOSUS. 

Description. — Lupus  erythematosus  is  a  cellular  infil- 
tration of  the  skin,  characterized  by  erythematous  patches 
of  various  sizes  and  shapes,  generally  decked  with  grayish 


276  NEW  GROWTHS 

or  yellowish  adherent  scales,  and  displaying  a  tendency 
to  superficial  scarring. 

There  are  several  clinical  varieties  of  the  disease  recog- 
nized by  authors.  By  far  the  most  common  is  the  discoid 
or  circumscribed  form,  in  which  the  primary  or  eruptive 
lesion  is  from  pin-head  to  pea-sized,  slightly  raised,  and 
which  presently  becomes  covered  with  an  adherent  scale. 
These  spots  may  be  isolated  or  grouped,  few  or  many,  but 
gradually,  by  peripheral  extension  and  coalescence,  they 
come  to  make  variously  sized  and  shaped,  erythematous, 
scaly  patches  that  are  characteristic.  The  patch  is  pinkish, 
reddish  or  purplish  in  color,  and  the  surface  is  in  some 
cases  covered  with  scanty  adherent  scales,  or  else  with  thick, 
yellow  and  sebaceous-looking  crusts,  or  in  still  other 
instances  the  lesions  are  frankly  erythematous  and  free  of 
scales.  The  patch  spreads  peripherally,  and  finally  exhibits 
a  depressed,  atrophic  centre,  with  a  raised  border,  stud- 
ded with  comedones  or  showing  small,  patulous  openings. 
There  may  be  one  or  more  such  lesions  present,  varying  in 
size  from  that  of  a  pea  to  that  of  the  palm. 

The  progress  of  the  disease  is  usually  very  slow,  often 
extending  over  years,  but  occasionally  the  evolution  is 
much  more  rapid.  After  awhile  the  affection  ceases  to 
spread  and  comes  to  a  standstill,  or  involution  may  be 
complete  and  nothing  remain  but  a  superficial  or  deep, 
usually  punctiform,  scar.  When  hairy  parts  are  affected 
the  hairs  fall  out  as  the  result  of  follicular  atrophy.  The 
usual  seat  of  the  disease  is  upon  the  face,  especially  over 
the  bridge  of  the  nose,  and  also  the  tip  and  alae,  on  the 
cheeks,  eyelids,  scalp,  and  ears.  One  of  the  most  character- 
istic types  of  the  affection  is  exhibited  in  the  so-called 
butterfly  or  bat-like  form,  produced  by  coalescence  of 
patches  on  the  bridge  of  the  nose  and  on  the  cheeks  under 
the  eyes.  Other  parts  of  the  body  may  be  affected,  and 
attention  has  been  called  to  lupus  erythematosus  of  the 
hands  and  feet,  and  also  of  the  mucous  membrane  of  the 
lips,  mouth,  and  conjunctive.1 

See  Thomas  Smith,  British  Journal  of  Dermatology,  February, 
1906. 


LUPUS  ERYTHEMATOSUS  277 

The  subjective  symptoms  are  not  marked  and,  at  the 
most,  consist  of  slight  burning  or  itching.  In  the  ordinary 
forms  of  the  disease,  to  which  the  description  just  given 
applies,  the  patients  are  in  the  enjoyment  of  general  good 
health. 

In  the  form  of  the  disease  called  lupus  erythematosus 
disseminatus  there  are  many  aggregated  or  discrete,  usually 
(Tvthematous,  primary  eruptive  spots,  which,  unlike  the  dis- 
coid variety,  spread  by  the  multiplication  of  these  lesions, 
and  not  by  their  coalescence;  and  thus,  by  the  appear- 
ance of  new  patches  among  the  older,  large  surfaces  may  be 
involved,  and  almost  any  part  of  the  body  occupied  by  the 
eruption. 

Grave  constitutional  and  local  disorders  may  complicate 
this  affection,  and  a  fatal  termination  has  ensued  in  a 
large  proportion  of  the  cases.  One  of  us  reported  two 
instances  of  this  formidable  disease,  both  ending  in  death.1 
There  is  a  strong  suspicion  in  our  minds  that  these  cases, 
like  some  of  the  discoid  forms,  especially  the  indurated, 
unsymmetrical  variety — the  lupus  e'rythe'mateux  fixe  of 
Brocq — are  really  examples  of  cutaneous  tuberculosis. 

Crocker  describes  a  telangiectatic  and  a  nodular  form, 
In  the  first-named  variety  there  is  a  chronic,  erythema-like 
redness,  due  to  dilatation  of  vessels,  accompanied  by  con- 
siderable infiltration,  and  later,  by  superficial  scarring. 
It  may  be  single,  but  usually  occupies  both  cheeks.  We 
have  also  seen  it  in  the  form  of  disseminated  patches.  The 
second,  or  nodular  variety  does  not  present  a  very  definite 
clinical  picture,  and  would  seem  to  consist  of  brownish-red 
nodules,  not  unlike  lupus  vulgaris,  but  which  from  their 
course  and  general  behavior  bear  a  resemblance  to  lupus 
erythematosus. 

Lupus  erythematosus  is  much  more  common  in  women 
than  in  men,  and  usually  first  makes  its  appearance  between 
tke  ages  of  eighteen  and  forty,  although  a  few  cases  in 
children  have  been  recorded.  The  etiology  of  the  disease 

1  Hardaway,  Journal  of  Cutaneous  Diseases,  December,  1889,  and 
July,  1892. 


278  NEW  GROWTHS 

is  very  obscure,  but  it  is  likely  that  both  debilitating  influ- 
ences and  local  irritations  predispose  to  it.  For  example, 
Hutchinson  and  others  state  that  a  history  of  phthisis  in 
the  family  is  often  obtainable,  and  it  is  undoubtedly  true 
that  tuberculosis  is  often  associated  with  the  disseminated 
type.  It  would  seem  that  uterine  derangements  and 
chlorotic  states  often  exist  as  antecedents  or  complications; 
and,  moreover,  heat  and  cold  and  the  various  agents 
that  dispose  to  seborrhea  are  undoubted  exciting  causes. 
Wilfrid  Ward  has  shown  the  frequent  connection  of  lupus 
erythematosus  with  hypertrophic  and  atrophic  rhinitis,  with 
or  without  ozena. 

Prognosis. — Prognosis  should  always  be  guarded,  as 
the  disorder  runs  a  very  variable  course,  and  a  plan  of 
treatment  that  is  successful  in  one  case  will  be  of  no  effect 
in  the  next.  Some  of  the  superficial  forms  of  the  disease 
are  quite  amenable  to  treatment,  and  in  the  more  chronic- 
patches,  even  if  a  cure  cannot  always  be  accomplished, 
decided  amelioration  may  be  secured.  Relapses  may  be 
expected.  The  disseminated  form  is  of  grave  import. 

Treatment. — The  internal  treatment  of  the  disease  con- 
sists, for  the  most  part,  in  the  employment  of  remedies  to 
improve  the  general  health  or  for  the  correction  of  obvious 
complications.  Some  observers  think  they  have  seen  good 
results  from  the  direct  action  of  certain  drugs  on  the  dis- 
order itself.  We  quite  agree  with  Leredde,  however,  in 
the  statement  that  the  large  number  of  therapeuticjil 
agents  recommended  in  lupus  erythematosus  is  merely 
due  to  the  fact,  often  observed  in  other  dermatoses,  that 
certain  types  tend  to  spontaneous  recovery.  J.  C.  White's 
skepticism  as  to  the  value  of  treatment  in  this  affection  is 
well  known.  So  far  as  regards  the  internal  administration 
of  drugs  in  chronic  forms  of  lupus  erythematosus,  we 
have  seen  no  benefit  from  their  employment,  excepting,  of 
course,  remedies  such  as  cod-liver  oil,  the  hypophospliitrs, 
iron,  etc.,  directed  to  the  improvement  of  the  general 
health  or  the  removal  of  complications.  We  cannot  say, 
either,  that  we  have  witnessed  any  appreciable  benefit  from 


LUPUS  ERYTHEMATOSUS  279 

diet,  although  on  general  principles  the  patient  should  be 
directed  to  avoid  stimulating  foods  and  drinks. 

In  acute  cases  of  the  disease  there  is  some  reason  to 
believe  that  certain  remedies,  given  internally,  have  a 
beneficial  action.  Crocker's  original  suggestion  of  the 
value  of  salicin  in  such  instances  has  apparently  been 
borne  out  in  our  own  experience.  The  drug  should  be 
given  in  doses  of  15  gr.  from  the  first.  It  is  best  ad- 
ministered in  capsules  or  wafers. 

Saline  cathartics  in  appropriate  doses  may  be  ordered  at 
the  same  time,  preferably  a  suitable  dose  every  morning 
before  breakfast.  Payne  advises  quinine  in  large  doses 
under  the  same  circumstances,  and  Unna  gives  ichthyol. 
None  of  these  drugs  is  of  any  value  in  chronic  infiltrated 
patches  of  the  disease. 

Hollaender's  combined  internal  and  local  treatment  by 
quinine  and  iodine  may  be  mentioned  here. 

In  the  beginning,  the  patient's  tolerance  is  tested  in 
regard  to  quinine,  and  then  the  drug  is  pushed  to  about 
7  gr.,  three  times  a  day.  Five  or  ten  minutes  after  taking 
the  dose,  the  diseased  area  is  painted  with  tincture  of 
iodine.  This  is  continued  for  a  week,  and  after  a  short 
pause  again  repeated.  Morris  and  others  have  reported 
some  good  results  from  this  method. 

Arsenic  (Hutchinson)  iodide  of  starch  (Anderson)  and 
phosphorus  have  been  prescribed  with  asserted  advantage. 

Bulkley1  claims  brilliant  results  from  the  last-men- 
tioned agent  given  in  solution  as  follows: 

1$ — Phosphorus pr.  \  j 

Absolute  alcohol      ....'....     oxxx 

To  be  dissolved  with  the  aid  of  heat  and  agitation,  and 
then  mixed,  while  still  warm,  with  the  following  mixture, 
also  warm: 

ty— Glycerin 3'ixss 

Alcohol 

Essence  of  peppermint oss 

1  American  Journal  of  Medical  Sciences,  April,  1893. 


280  NEW  GROWTHS 

The  dose  is  15  drops  in  water,  taken  quickly  to  prevent 
oxidation,  three  times  a  day  after  meals,  and  gradually 
increased  to  45  or  50  drops.  The  value  of  the  phosphorus 
treatment  has  been  confirmed  by  other  observers.  Legrain 
employed  injections  of  sheep  serum  successfully  in  a  case, 
using  two  injections  of  10  c.c.  at  intervals  of  five  days. 

The  local  treatment  is,  however,  of  far  greater  impor- 
tance, and,  according  to  the  symptoms  present  in  a  given 
case,  may  be  soothing,  stimulating,  or  destructive.  For 
the  first  purpose  the  calamine  and  zinc  lotion,  to  each 
ounce  of  which  may  be  added  10  minims  of  liq.  carbonis 
detergens,  is  admirably  adapted.  Often,  by  such  mild 
measures,  patches  may  be  made  to  disappear  without  sub- 
sequent scarring.  In  other  cases  of  a  more  chronic  char- 
acter, but  where  the  infiltration  is  moderate,  various 
astringent  applications  may  be  tried.  Duhring's  lotion  of 
sulphate  of  zinc  and  sulphide  of  potassium  is  very  valuable : 

~Bf — Zinci  sulphatis, 

Potassse  sulphuratse aa     oss 

Aquse  rosae Bijjss 

Alcoholis 3iij — M. 

S. — Mop  on  morning  and  evening  for  ten  or  more  minutes  at 
a  time. 

Among  other  remedies  of  this  class  may  be  mentioned 
Lassar's  paste  modified  as  follows: 

1^ — Zinci  oxidi oij 

Pulv.  talci 5ij 

Vaselini oiv 

And  Pick's  linimentum  exsiccans  in  this  combination: 

1^ — Liq.  carbonis  detergentis n\x 

Zinci  oxidi oj 

Linimenti  exsiccantis 3j — M. 

Crocker  recommends  contractile  collodion  for  its  effect 
on  the  vessels.  Unna  employs  ichthyol  in  combination 
with  the  collodion: 

1$ — Ichthyolis 5ss 

Collodii 3v— M. 


LUPUS  ERYTHEMATOSUS  281 

H.  Hebra  suggested  the  frequent  application  of  alcohol, 
or  of  equal  parts  of  alcohol,  spirit  of  mint,  and  ether. 

In  sluggish  cases,  especially  of  the  sebaceous  type,  more 
stimulating  remedies  are  demanded.  The  elder  Hebra 
particularly  recommended  rubbing  in  the  tincture  of  green 
soap  (equal  parts  of  green  soap  and  alcohol)  followed 
by  an  emollient  salve.  Oil  of  cade  may  be  added  to  this 
preparation  in  the  strength  of  1  to  2  drachms  to  1  oz. 
(Crocker).  The  green  soap  may  be  used  alone  for  this 
purpose,  or  it  may  be  spread  as  a  plaster  on  flannel.  The 
soap  treatment  is  very  valuable,  as  it  not  only  removes 
the  scales  and  sebaceous  plugs,  but  distinctly  reduces 
the  infiltration.  After  a  few  days,  when  the  irritation 
from  the  application  has  subsided,  the  treatment  may  be 
renewed.  Crocker  states  that  neither  the  soft  soap  nor  the 
tincture  of  soap  should  be  used  where  there  is  active  con- 
gestion, or  it  will  very  likely  aggravate  the  eruption.  This 
warning  holds  good  for  all  remedies  of  this  class,  for  we 
have  more  than  once  seen  a  quiescent  patch  roused  to 
activity  by  too  energetic  interference. 

Crocker  speaks  in  the  highest  terms  of  Hutchinson's 
treatment  with  benzolin.  It  should  be  used  with  moderate 
friction  and  followed  by  a  mild  antiseptic  salve  of  iodo- 
form  (5  gr.  to  1  oz.)  or  of  boric  acid.  It  should  be  applied  at 
night,  and  calamine  lotion  mopped  on  during  the  day.  If 
the  benzolin  sets  up  any  irritation,  the  number  of  applica- 
tions may  be  reduced  to  two  or  three  a  week. 

Another  remedy,  that  we  have  occasionally  used  with 
good  results,  is  the  often-quoted  combination  of  salicylic 
acid  and  sulphur. 

]$ — Acidi  salicylic! oss 

Sulphuris  pnecip 5j 

Vaselini 5j — M. 

S. — Rub  in  vigorously  twice  daily. 

In  old  patches  the  application  of  the  salicylic  acid 
plaster  mull  helps  matters  very  much,  and  we  often  apply 
it  before  commencing  with  the  salve  just  mentioned. 


282  NEW  GROWTHS 

In  more  indolent  and  resistant  patches  stronger  remedies 
may  be  tentatively  tried.  Indeed  the  number  of  such 
agents  is  almost  beyond  reckoning,  and  indicates,  as  a 
matter  of  course,  the  rebelliousness  and  capriciousness 
of  the  disorder  itself;  but,  nevertheless,  Kaposi's  remark  is 
true  enough,  that  no  one  remedy  can  be  depended  upon  for 
all  cases,  or  even  for  the  same  case  at  different  periods  of 
its  progress.  Stelwagon  quotes  with  approval  G.  H.  Fox's 
plan  of  painting  over  the  plaques  with  pure  liquid  carbolic 
acid.  Two  or  three  patches  only  should  be  treated  at  the 
same  time,  and  the  application  may  be  repeated  after  the 
crust  has  separated,  that  is,  in  about  a  week  or  ten  days. 
Hyde  and  Montgomery  advise  the  topical  application  of  a 
saturated  solution  of  pyoktanin  blue.  The  solution  is 
thickly  painted  over  the  entire  portion  affected,  and  the 
application  may  be  repeated  for  a  long  period.  En/ymol 
is  also  recommended  by  the  same  authors. 

Painting  with  liquor  potassse,  pure  or  diluted  according 
to  circumstances,  is  well  spoken  of  by  both  Crocker  and 
Stelwagon.  .The  latter  recommends  that  after  the  liquor 
potassse  has  dried  on  the  skin,  two  or  three  coats  of  collo- 
dion should  be  painted  over  it,  the  process  being  repeated 
every  two  or  three  days. 

Salicylic  acid  in  collodion,  from  15  to  30  gr.  to  1  oz., 
painted  over  the  eruption,  and  repeated  from  time  to  time, 
is  sometimes  very  serviceable,  but,  as  a  rule,  we  prefer 
the  salicylated  soap  plasters  in  from  5  to  20  per  cent, 
strength,  especially  the  formula  containing  camphor  given 
under  Eczema  (p.  93). 

Resorcin  is  another  remedy  of  the  same  class,  which 
may  be  used  in  from  2  to  10  per  cent,  strength.  Stelwagon 
advises  a  10  to  50  per  cent,  strength  in  alcoholic  solution, 
if  in  collodion  a  3  to  20  per  cent,  strength.  Mracek  prefers 
it  in  the  form  of  Lassar's  scaling  paste : 

1$ — Beta-naphtholi Sijss 

Sulphur  prircip 3x 

Vaselini, 

Saponis  viridis aa  5vj-gr.  xv — M 


LUPUS  ERYTHEMATOSUS  283 

Pyrogallol  is  recommended  by  Veiel  in  10  per  cent, 
ointment,  which  should  be  kept  on  for  three  or  four  days 
or  until  a  crust  forms,  and  when  this  separates  the  surface 
should  be  dressed  with  iodoform  or  some  similar  powder. 
Pyrogallol  is  also  used  as  a  paint  in  combination  with 
salicylic  acid,  namely,  salicylic  acid,  1  part;  pyrogallol, 
3  parts,  and  flexible  collodion,  40  parts.  It  is  employed  in 
much  greater  strength  by  Brooke: 

1$ — Acidi  salicylic! oij 

Pyrogallol 5ss 

Collodii 5v — M. 

Schutz  recommends  a  weak  solution  of  arsenic,  1  in  400 
to  (500,  or  Fowler's  solution  in  one-fourth  or  one-sixth  of 
its  strength,  for  local  use.  This  may  be  painted  over  the 
patches  twice  a  day,  but  in  about  a  week  or  even  in  less 
time,  as  we  have  found,  the  affected  parts  become  irritated, 
in  which  event  the  applications  should  be  intermitted  and 
a  simple,  protective  paste  applied.  The  lotion  and  the  paste 
may  be  then  alternated  for  several  weeks. 

In  cases  having  hard,  horny  scales  Veiel  prefers  chlora- 
cetic  acid.  It  is  put  on  with  a  glass  rod,  and  soon  produces 
a  white  eschar,  and  into  this  is  bored  a  pointed  glass  rod 
dipped  into  the  acid.  This  has  been  a  satisfactory  method 
in  our  hands  in  selected  cases. 

G.  H.  Fox  and  Dade  obtained  excellent  results  by  deep 
freezing  with  liquid  air.  It  should  be  used  with  caution. 

Many  years  ago,  one  of  us1  employed  and  recommended 
electrolysis  in  certain  types  of  lupus  erythematosus,  and 
an  extended  experience  has  confirmed  him  in  his  good 
opinion  of  this  method.  It  is  very  useful  in  small  infiltrated 
patches,  and  if  carefully  done  need  not  produce  any  great 
amount  of  scarring.  Even  in  relatively  recent  cases  pre- 
senting more  or  less  superficial  lesions,  tattooing  with  the 
electrolytic  needle  will  cause  their  disappearance  without 
any  noticeable  destruction  of  the  skin.  In  an  extremely 
persistent  telangiectatic  case  a  brilliant  result  was  obtained 
by  electrolysis. 

1  Hanlaway. 


284  XEW  GROWTHS 

Various  surgical  procedures  have  been  employed  in  the 
treatment  of  lupus  erythematosus,  such  as  linear  scari- 
fication, curettage,  and  even  excision.  The  method  of 
linear  scarifications  is  to  be  preferred  to  other  methods 
and  also  to  the  use  of  strong  caustics. 

For  this  operation  one  may  employ  any  of  the  knives 
made  for  this  purpose,  preferably  Pick's  modification  of 
Veiel's,  Squire's  or  Van  Harlingen's.  Parallel  incisions 
are  made  that  are  about  one-sixteenth  of  an  inch  apart, 
and  these  are  crossed  by  another  series,  and  even  a  third. 
The  parts  should  be  first  frozen  with  rhigoline  spray,  and 
the  hemorrhage  that  follows  may  be  checked  by  pressure 
with  absorbent  cotton  and  the  wound  dressed  with  iodo- 
form.  It  is  well  to  operate  on  limited  patches  at  a  time, 
and  it  is  usually  necessary  to  repeat  the  operation  several 
times.  (See  Scarification,  Part  H) 

Today,  however,  we  think  it  may  be  said  that  so-called 
radical  methods  of  treatment  are  being  more  and  more 
abandoned,  and  where  the  milder  methods  of  treatment 
have  proved  unavailing,  recourse  is  had  to  phototherapy, 
the  x-rays,  or  the  high-f  requency  current. 

The  same  difficulty  obtains  in  judging  the  merits  of 
these  new  procedures  as  with  the  older  methods,  and  for 
similar  reasons. 

The  results  obtained  by  Finsen,  Leredde  and  Pautrier, 
Morris  and  Dore,  Gaston,  Baudouin  and  Chat  in,  and 
Hyde,  Ormsby  and  F.  H.  Montgomery,  summed  up  by 
the  last  named  in  December,  1903,  give  totals  of  94  cases, 
with  36  cured  and  28  improved.  Such  statistics,  however, 
are  not  very  significant,  in  view  of  the  wide  variety  of 
lamps  employed.  Sequeira  failed  in  one-half  of  14  patients. 
Gottheil  had  3  apparent  cures,  but  1  case  recurred  within 
the  year.  The  method  is  not  advised  in  the  aberrant 
types  of  the  disease.  Cases  that  we  have  treated  with  a 
modified  lamp  and  the  results  that  we  have  occasionally 
seen  at  the  hands  of  others  have  not  been  encouraging. 
Hyde  and  Montgomery  state  that  the  lesions  in  which  the 
vascular  element  predominates,  or  which  are  subacute  in 


LUPUS  ERYTHEMATOSUS  285 

type,  do  better  with  phototherapy  than  with  the  x-rays,  and 
that  cases  with  marked  infiltration  and  decided  involve- 
ment of  the  glands  and  follicles  resist  the  light  treat- 
ment and  improve  more  rapidly  under  the  x-rays. 

The  X-rays. — In  few  affections  are  published  reports  so 
antipodal.  While  the  majority  of  observers  have  little 
praise  for  the  method,  a  few  have  obtained  cures  which  can 
only  be  described  as  startling.  Thus,  James  Startin  reports 
a  case,  long  stubborn  to  other  agents,  cured  in  six  sittings, 
and  Wood,  1  of  four  years'  duration  cured  in  five  ten- 
minute  sittings.  Most  extraordinary  of  all,  however,  is 
O  udin's  case.  A  woman ,  aged  twenty-nine  years,  had  a  small 
patch  on  each  cheek.  She  had  been  treated  without  success 
by  Fournier,  Anderson,  and  Crocker.  High-frequency 
currents  were  of  no  avail.  Oudin  irradiated  the  lesions  for 
three  successive  days — one-half  minute  the  first  day,  one 
minute  the  second,  and  one  minute  and  one-half  the  third. 
On  the  fourth  day  the  lesions  were  much  better,  and  by 
the  fifth  had  almost  disappeared.  After  an  interruption, 
five  or  six  more  sittings  were  given  of  from  one  to  one 
and  one-half  minutes  each.  The  patient  was  seen  forty- 
six  days  after  the  first  sitting  and  was  found  completely  cured. 
We  must  remember  in  this  connection  that  Oudin  works 
with  a  red-hot  target  and  a  soft  tube  brought  within  two 
inches  of  the  skin. 

Pusey  has  observed  marked  improvement  from  this 
agent,  but  never  a  complete  cure.  He  uses  mild  exposures 
at  intervals  of  two  or  three  days.  We  have  obtained  one 
cure,  and  great  amelioration  in  a  few  cases,  while  others 
have  apparently  been  harmed. 

Belot  declares  that  in  this  most  obstinate  disease  x-rays 
give  no  better  results  than  other  modes  of  treatment.  It  is 
at  least  certain  that,  having  determined  to  employ  irradia- 
tion, we  should  only  do  so  with  the  greatest  circum- 
spection. 

Sabouraud  dismisses  the  subject  of  treatment  with  high- 
frequency  currents  with  the  curt  statement  that  they  have 
been  tried  without  satisfactory  results.  This  opinion  is  by 


286  NEW  GROWTHS 

no  means  shared  by  his  colleagues  in  France.  Both 
Brocq  and  Leredde,  and  Pautrier,  regard  this  method  with 
especial  favor.  Jacquet  reports  56  cases  with  39  cures. 
Bisserie',  62  cases  with  33  cures. 

Stelwagon  in  this  country  speaks  highly  of  the  high- 
frequency  current  in  some  cases.  So  far  as  our  experience 
extends  we  can  endorse  much  that  has  been  said  in  its  favor. 
We  have  used  a  flat  vacuum  electrode  held  at  a  distance  of 
one-fourth  to  one-half  inch,  and  the  sittings  have  been  given 
twice  a  week,  and  in  some  cases  daily.  Radium  bromide 
has  been  used  with  many  times  its  bulk  of  barium  chloride, 
the  radio-activity  of  the  mixture  varying  from  1000  to 
5200  (Danlos).  This  is  enclosed  in  a  caoutchouc  bag  and 
fastened  over  the  lesion  for  from  twenty-four  to  forty-eight 
hours.  Strassmann  obtained  a  cure  in  3  cases. 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Pyrogallol oss 

Acidi  salicylici 5ij 

Collodii 5v — M. 

S. — External  use.    In  chronic  conditions.  Jessner. 

]ty— Tr.  iodi, 

Chloral,  hydratis, 

Acidi  carbolici ai     oj—  M. 

S. — External  use.    For  infiltrated  patches.  Cutler. 

1^ — lodoformi gr.  xl 

Ft.  pil.  No.  xl. 

S. — 1  to  3  pills  three  times  a  day.  Besnier-Whitehouse. 

1^ — Zinci  oxidi oj 

Magnes.  carb ojss 

Hoi.  albiP ojss 

Hoi.  rubnr oj 

Amyli  oryzae 5v — M. 

S. — Powder.    In  acute  cases.  Unna. 

1^ — Zinci  pxidi, 

Amyli. 

Glycerini aa     5ij 

I,i(|.  alum,  neet., 

Aqu:r  di'stillat:i» fifi      ."vijss— M. 

S. — External  application  in  acute  types.  Jessner. 


THE  SYPHILODERMATA  287 


1$ — Acidi  salicylic! .  oss 

Acidi  lactici 5ss 

Resorcini gr.  xlv 

Zinci  oxidi oij 

Vaselini •  Sxvij — M. 

S. — External  use.  Brocq. 


THE  SYPHILODERMATA. 

Description. — Syphilis  is  a  chronic,  infectious  disease 
that  first  makes  its  appearance,  after  a  varying  period  of 
incubation,  in  the  shape  of  the  so-called  initial  lesion,  or 
chancre,  which  in  turn,  after  a  second  period  of  incubation, 
is  followed  by  the  constitutional  manifestations  of  the 
disease.  While  every  tissue  and  organ  of  the  body  may  be 
involved,  the  dermatologist  is  mainly  concerned  with  the 
disorder  as  it  presents  itself  on  the  skin.  Before  entering 
upon  a  brief  description  of  the  various  eruptions  which 
may  develop,  it  will  be  well  to  take  a  brief  view  of  the 
syphilodermata  as  a  whole,  and  to  point  out  certain  more 
or  less  characteristic  features  in  their  course  and  general 
characters  wherein  they  resemble  each  other,  and  differ 
from  the  non-specific  affections  of  the  integument.  Among 
the  peculiarities  of  syphilitic  eruptions  most  worthy  of  atten- 
tion are  the  following: 

Location  and  Configuration. — Syphilitic  eruptions  may 
occur  anywhere  on  the  body,  but  the  various  special  va- 
rieties would  seem  to  have  a  preference  for  certain,  fairly 
definite  sites.  For  example,  the  early  erythematous  syphi- 
loderm  is  usually  to  be  found  on  the  sides  of  the  chest, 
abdomen,  loins,  the  flexor  surfaces  of  the  arms,  and  inner 
sides  of  the  thighs;  papular  lesions  develop  in  the  same 
localities,  as  well  as  upon  the  palms,  soles,  forehead,  at  the 
margin  of  the  scalp,  and  on  the  neck;  the  pustular  forms  are 
observed  in  the  same  situations  as  the  last-mentioned 
variety,  but  also  on  the  legs  and  in  the  hairy  parts  of  the 
face  and  scalp;  the  rupial  and  ecthymatous  syphilides 
affect  the  face  and  extremities;  the  squamous  lesions  the 


288  NEW  GROWTHS 

palms  and  soles.  Moist  papules  seek  the  mucous  outlets; 
tubercular  lesions  the  forehead,  the  back  of  the  neck  and 
the  shoulders,  and  the  junction  of  the  nose  and  cheek; 
and  the  gummatous  infiltrations  are  to  be  noted  about  the 
joints. 

The  early  cutaneous  manifestations  are  symmetrically 
disposed,  and  bear  the  character  of  a  more  or  less  general- 
ized eruption;  but  later,  while  the  symmetrical  arrange- 
ment is  retained,  a  tendency  to  group  and  form  circles  and 
segments  of  circles  is  a  notable  and  characteristic  feature; 
and  the  tardiest  varieties  lose  the  symmetrical  disposition, 
and  occupy  comparatively  isolated  and  limited  regions. 

Polymorphism. — The  presence  of  many  different  ele- 
mentary lesions  at  one  and  the  same  time,  that  is,  macules, 
papules,  pustules,  etc.,  while  seen  in  some  of  the  simple 
disorders,  if  taken  in  connection  with  other  phenomena,  is 
of  considerable  diagnostic  value. 

Course. — Syphilis  is  essentially  a  chronic  disease,  and 
the  syphilodermata  lack  the  inflammatory  features  of  the 
non-specific  eruptions.  The  different  original  forms  also 
exhibit  a  tendency,  by  a  process  of  evolution,  to  develop 
into  other  forms,  e.  g.,  from  a  papule  into  a  tubercle,  and 
the  latter  may  undergo  a  purulent  degeneration. 

Color. — Syphilitic  eruptions  are  by  no  means  always  of 
the  same  shade  of  color,  this  feature  varying  much  with 
the  age  of  the  lesions,  their  locality,  etc.,  but  they  may  be 
said  as  a  general  thing  to  possess  a  ham  or  copper  color, 
especially  in  the  large  papular  and  tul>ercular  varieties  of 
lesion;  and  while  other  skin  diseases  may  show  this  tint  in 
some  instances,  this  symptom  must  be  given  due  weight  in 
differential  diagnosis.  The  pigmentation  left  after  the 
subsidence  of  syphilitic  eruptions  is  not  peculiar  to  this 
disease,  being  seen  in  lichen  planus  and  upon  the  lower 
extremities  after  eczema;  but  it  possesses  somewhat  more 
significance  when  situated  on  the  trunk  or  upper  limbs. 

Absence  of  Itching  and  Pain. — A  broad  general  rule  of 
great  value  in  the  diagnosis  of  specific  eruptions  is  the  one 
relating  to  the  absence  of  subjective  symptoms,  namely, 


THE  SYPHILODERMATA  289 

itching  and  pain,  and  while  this  fact  is  by  no  means  to  be 
regarded  as  pathognomonic,  there  being  some  exceptions, 
it  remains,  nevertheless,  one  of  our  best  differential  points. 

Other  Peculiarities. — Among  other  peculiarities  of  syphili- 
tic eruptions,  attention  may  be  called  to  the  characters  of 
the  scales,  crusts,  ulcers,  and  scars.  The  scales  are  a  dirty 
white  or  grayish,  are  quite  scanty,  and  do  not  possess  the 
glistening  aspect  and  imbricated  arrangement  seen  in 
psoriasis,  for  example.  The  crusts  are  dark  brown  or  have 
a  greenish  tint,  are  usually  thick  and  rough;  in  rupia  they 
are  heaped  up  after  the  manner  of  an  oyster  shell.  The 
ulcers  of  syphilis  may  assume  various  shapes,  but  the 
kidney-shaped  and  horseshoe  form  is  quite  characteristic. 
Their  borders  are  generally  sharply  cut.  Syphilitic  scars 
are  round  or  oval,  and,  except  in  the  neighborhood  of 
joints,  quite  soft  and  pliant,  and  not  traversed  by  bands 
and  cords.  In  old  scars  the  white,  glistening  centre,  and 
the  peripheral  ring  of  pigmentation  may  be  also  mentioned. 

Finally,  in  establishing  a  diagnosis,  it  must  be  repeated 
that  no  one  single  symptom  taken  by  itself  will  suffice  in 
all  cases  and  at  all  times;  on  the  contrary,  the  case  must 
be  studied  as  a  whole,  and  the  history  and  the  concomi- 
tants, namely,  the  glandular  enlargements,  the  mucous 
involvements,  and  such  other  local  or  general  symptoms  as 
may  be  present  must  be  given  due  weight. 

The  following  types  of  eruption  will  now  be  briefly 
considered : 

1.  Syphiloderma  erythematosum. 

2.  Syphiloderma  papulosum. 

3.  Syphiloderma  pustulosum. 

4.  Syphiloderma  tuberculosum. 

5.  Syphiloderma  gummatosum. 
(>.  Syphiloderma  bullosum. 

Syphiloderma  Erythematosum.  (Syn.  Macular  Syphilide, 
Syphilitic  Roseola,  Erythematous  Syphilide,  Exanthematous 
Syphilide,  Syphilis  Cutanea  Maculosa.) — The  erythematous 
syphiloderm,  or  syphilide,  is  usually  the  earliest  cutaneous 
manifestation,  appearing  in  six  or  eight  weeks  from  the 
19 


290  NEW  GROWTHS 

development  of  the  initial  lesion.  The  favorite  regions  of 
attack  are  the  sides  of  the  chest,  the  lower  part  of  the  belly, 
the  flanks,  and  the  flexor  surfaces  of  the  limbs.  The  face, 
backs  of  the  hands,  and  feet  are  generally  spared.  The 
macules  are  of  about  the  size  of  a  silver  ten-cent  piece, 
sometimes  larger  or  smaller,  of  a  red  color,  which  later 
becomes  violaceous  and  finally  pigmented.  At  first  they 
may  be  made  to  fade  on  pressure,  but  afterward  they 
cannot  be  effaced  Usually  the  macules  are  not  elevated 
above  the  level  of  the  skin,  but  at  times  the  eruption  assumes 
a  maculopapular  character,  and  in  the  further  evolution  of 
the  disease  the  lesions  may  become  frankly  papular  and 
even  pustular.  Subjective  symptoms,  if  present  at  all,  are 
very  slight. 

Relapses  of  the  erythematous  syphiloderm  sometimes 
occur,  taking  place  during  the  first  year.  They  are  apt  to 
be  localized,  and  the  lesions  show  a  tendency  to  assume 
the  circinate  form. 

What  is  known  as  the  pigmentary  syphilide  is  a  compara- 
tively rare  expression  of  the  disease.  It  appears  early  or 
late  in  the  course  of  the  affection,  is  more  frequent  in 
females,  and  is  usually  seated  upon  the  lateral  surfaces  of 
the  neck.  At  first  sight  the  affected  parts  look  as  if  they 
were  dirty,  but  a  closer  inspection  will  discover  irregularly 
round  or  oval  spots  of  a  light  chocolate  color  that  are  not 
very  sharply  defined. 

Syphiloderma  Papulosum.  (Syn.  Papular  Syphilide, 
Syphilis  Cutanea  Papulosa.) — The  small  papular,  or  miliary 
papular  syphiloderm  varies  in  size  from  a  pin's  head  to  a 
linseed,  is  rounded  or  acuminate,  of  a  bright-red  color  in 
the  beginning,  but  gradually  takes  on  a  darker  hue.  The 
eruption  may  be  scattered  or  grouped,  sometimes  arranged 
in  patches,  and  is  most  freely  developed  on  the  trunk. 
Some  of  the  papules  are  capped  by  minute  vesicles  or 
vesicopustules.  The  eruption  makes  its  appearance  in 
two  or  three  months  from  the  development  of  the  chancre, 
is  very  chronic,  and  prone  to  relapse.  When  the  papules 
undergo  involution  they  leave  behind  pigmentation  and 
shallow,  atrophic  pits. 


THE  SYPHILODERMATA  291 

This  form  of  eruption  should  not  be  confounded  with 
papular  eczema,  keratosis  pilaris,  or  lichen  planus  (q.  v.}. 

The  large  papular  syphilodenn  (lenticular  syphilide)  is 
a  common  and  characteristic  type  of  syphilitic  eruption. 
The  lesions  vary  in  size  from  a  split  pea  to  a  small  coin,  are 
flat  or  hemispherical,  thoroughly  defined,  smooth,  glisten- 
ing, and,  in  the  later  stages,  of  a  decided  ham  color.  They 
come  out  quite  freely,  and  in  the  beginning  may  be  widely 
disseminated,  appearing  on  the  trunk,  face,  forehead 
(corona  veneris),  scrotum,  labia,  anus,  etc.  This  syphilo- 
derm  may  appear  early  or  late  in  the  disease  and  is  apt  to 
relapse.  The  papules,  after  persisting  for  a  variable  period, 
disappear  by  absorption,  followed  by  pigmented,  atrophic 
spots  that  gradually  turn  white. 

Occasionally,  and  especially  in  negroes  (Atkinson),  in 
connection  with  this  eruption  there  develops  on  the  neck 
or  in  the  region  of  the  mouth  or  forehead  the  annular 
syphilodenn,  which  consists  of  a  flattened  centre  surrounded 
by  an  elevated,  non-scaly  or  slightly  scaly  wall.  Several 
such  lesions,  discretely  arranged,  may  be  present,  or  the 
eruption  may  be  in  the  shape  of  interlacing  segments. 

Important  modifications  of  the  papular  syphiloderm 
are  the  moist  papule  and  the  papulosquamous  form  of 
eruption. 

Moist  Papule.  (Syn.  Mucous  Patch,  Broad  or  Flat  Con- 
dyloma.) — This  lesion  varies  in  size  from  a  pin's  head  to  a 
small  coin,  the  large  condylomata  being  formed  by  the 
coalescence  of  those  of  smaller  diameter.  A  common 
situation  for  the  moist  papule  is  in  regions  that  are  more  or 
less  in  contact,  heat  and  moisture  favoring  their  develop- 
ment. Thus  they  are  found  about  the  anal  and  genital 
regions  (in  women),  under  the  breasts,  between  the  toes, 
in  the  axillfe,  etc.  They  are  of  a  rather  soft  consistence, 
and  the  surface  is  usually  bathed  in  a  sticky,  mucoid  secre- 
tion that  is  highly  contagious  and  often  very  offensive. 
The  surface  is  generally  flat,  and  the  lesion  possesses  a 
well-defined  outline;  on  the  other  hand,  papillary  hyper- 
trophy may  develop,  resulting  in  elevated,  warty  growths, 


292  NEW  GROWTHS 

pouring  out  stinking  fluid  from  between  the  papillae,  which 
dries  into  yellowish-brown  crusts. 

The  term  mucous  patch  or  opaline  patch  is  generally 
limited  to  the  eruption  as  it  occurs  in  the  oral  cavity  and 
on  thp  lips.  As  a  general  thing  the  lesions  are  but  little 
elevated,  flat  and  sometimes  slightly  depressed,  grayish 
in  color,  and  at  times  very  painful. 

Papulosquamous  Syptiilodenn.  (Syn.  Squamous  Syphi- 
lide,  Psoriasis  Syphilitica,  Syphilis  Cutanea  Squamosa.) — At 
times  the  amount  of  scaling  is  so  marked  a  feature  of  the 
papular  eruption  as  to  warrant  the  designation  of  the  scaly 
syphiloderm,  or,  as  it  is  sometimes  unscientifically  termed, 
syphilitic  psoriasis.  The  eruption  is  generally  localized, 
and  the  scales,  which  are  of  a  dirty,  grayish  color,  are  not 
so  detachable  nor  profuse  as  in  psoriasis.  The  lesions 
may  be  discrete  or  form  groups,  and  by  fusion  develop  into 
patches  of  considerable  size,  and  in  the  further  march  of 
the  disease,  that  is,  by  simultaneous  evolution  and  involu- 
tion, various  ringed  and  gyrate  figures  may  be  formed,  quite 
as  in  psoriasis  vulgaris.  Papillary  hypertrophy  may  also 
take  place  in  addition,  with  the  result  of  producing  warty, 
vegetating  lesions  (syphilis  cutanea  vegetans). 

While  the  squamous  syphiloderm  may  be  found  upon 
any  portion  of  the  body,  the  palms  and  soles  are  particularly 
liable  to  attack. 

Palmar  and  Plantar  Syphiloderm. — This  syphiloderm 
is  very  chronic,  and  may  be  a  recent  or  late  manifestation. 
Syphilitic  papules  in  this  region  are  considerably  modified 
by  the  thickness  of  the  epidermis  and  the  traumatism  to 
which  they  are  necessarily  subjected.  The  various  specific- 
lesions  that  appear  upon  the  palms  do  not  all  go,  however, 
to  form  the  true  scaling  syphiloderm  of  this  region,  although 
under  certain  favoring  circumstances  this  transformation 
generally  occurs.  There  may  be  one  large  patch  or  several 
small  ones.  Scaling  follows,  and  even  fissures  and  ulcers. 
Exceptionally,  the  disease  creeps  along  with  a  crescentic 
margin  somewhat  elevated,  and  of  a  line  or  more  in  width. 
This  syphiloderm  must  be  distinguished  from  psoriasis 


THE  SYPHILODERMATA  293 

and  eczema.  Psoriasis  limited  to  the  palms  is  rare,  there 
generally  existing  lesions  of  the  disease  in  the  usual  situa- 
tions; squamous  eczema  usually  presents  more  infiltration, 
is  more  widely  spread,  and  is  attended  by  more  itching. 

Pustular  Syphilodenn.  (Syn.  Syphilis  Cutanea  Pustu- 
losa,  Pustular  Syphilide.) — This  syphiloderm  is  not  so  fre- 
quent as  the  varieties  just  described.  It  may  be  an  early  or 
late  manifestation,  originates  from  macules  or  papules,  and 
undergoes  various  modifications,  and,  according  to  cir- 
cumstances, is  termed  acne-form,  variola-form,  ecthyma- 
form,  etc.  In  the  interest  of  clinical  simplicity  it  will  be 
treated  under  the  following  heads: 

The  small,  acuminated,  pustular  syphiloderm  is  generally 
seated  upon  papular  bases,  about  the  size  of  millet  seed, 
that  have  their  origin  about  the  hair  follicles.  The  lesions 
may  be  grouped  or  disseminated,  may  involve  the  whole 
surface  or  be  localized,  the  latter  mode  of  development 
occurring  especially  in  relapses.  The  purulent  contents 
dry  into  crusts,  which  falling  off  display  a  collarette  of 
epidermis  around  the  base  of  the  lesions.  This  variety  of 
pustule  may  appear  early  or  late,  and  is  apt  to  relapse.  It 
is  not  unusual  to  discover  other  syphilitic  lesions  at  the 
same  time. 

The  large,  acuminated,  pustular  syphiloderm,  also  called 
the  acne-form  and  variola-form  syphiloderm,  is  formed 
about  a  hair  follicle  or  sebaceous  gland,  and  consists  of 
pustules  of  the  size  of  a  split  pea,  seated  upon  a  dark-red 
base.  While  occurring  upon  the  body  generally,  they 
select  by  preference  the  scalp,  shoulders,  and  face.  The 
pus  dries  into  rather  thick  crusts  of  yellowish-brown  color, 
and  are  sometimes  umbilicated,  that  is,  depressed  in  the 
centre,  and  underlying  this  is  some  degree  of  ulceration. 
It  is  an  early  manifestation,  and  somewhat  rare. 

This  syphiloderm  should  not  be  confused  with  smallpox 
in  the  pustular  stage — to  wrhich  the  lesional  resemblance  is 
very  close,  with  acne,  or  with  iodic  or  bromic  acne. 

The  small,  flat,  pustular  syphiloderm,  or  impetigo-form 
syphilide,  develops  in  the  form  of  small,  flat  pustules,  seated 


294  NEW  GROWTHS 

upon  reddish  bases,  the  pus  drying  into  thick,  yellowish,  or 
yellowish-brown  crusts.  The  lesions  may  be  isolated, 
grouped,  or  else  run  together  into  large  pustulocrustaceous 
patches.  The  surface  beneath  may  be  superficially  or 
deeply  ulcerated;  in  the  latter  event  the  eruption  is  either 
a  late  symptom,  or  has  developed  in  a  broken-down  sub- 
ject. 

This  syphiloderm  is  especially  encountered  on  the  scalp, 
genitals,  face,  and  limbs.  On  the  scalp  it  resembles  pus- 
tular eczema,  but  in  the  latter  affection,  in  addition  to  the 
pruritus,  there  is  absence  of  ulceration  beneath  the  crusts, 
and  of  the  repulsive  odor  usually  present  in  syphilis. 

The  large,  flat,  pustular  syphiloderm  occurs  late,  and 
manifests  itself  in  the  form  of  isolated,  unsymmetrical, 
large,  flat  lesions  having  a  deep-red  base.  Crusting,  the 
character  of  which  will  depend  upon  the  nature  of  the 
lesion,  soon  follows  the  appearance  of  the  eruption,  and  in 
every  instance  will  be  found  covering  underlying  ulcers. 
Two  varieties  are  described,  the  superficial  and  the  deep, 
the  difference  consisting,  among  other  things,  in  the  quality 
of  the  infiltration  and  the  character  of  the  subsequent 
ulceration.  The  crust  in  the  superficial  or  ecthymatous 
form  is  flat,  although  relatively  thick,  of  uneven  shape,  and 
of  brownish  or  blackish  color.  The  underlying  erosion  is 
not  very  deep,  and  secretes  a  yellowish  fluid ;  sometimes  the 
line  of  ulceration  extends  as  a  furrow  beyond  the  crust. 
This  syphiloderm  usually  attacks  the  trunk  and  extremi- 
ties, and  occurs  within  the  first  year  after  infection. 

The  crusts  of  the  deep  form  are  conical,  stratified  as  in 
the  oyster  shell,  and  are  of  a  black  or  greenish-black  color, 
and  quite  bulky.  Underneath,  the  ulceration  is  profound, 
and  the  floor  of  the  lesion  secretes  a  yellowish,  puriform 
fluid  upon  which  the  superimposed  crusts  may  be  said  to 
swim.  This  condition  is  called  rupia,  and,  so  far  as  we 
know,  has  no  analogue  among  the  non-specific  eruptions.  It 
must  be  stated,  however,  that  this  character  of  crust  is  not 
strictly  limited  to  the  lesion  in  question,  but  is  also  found  in 
the  so-called  bullous  and  even  in  the  tubercular  syphilo- 


THE  SYPHILODERMATA  295 

derm.  The  deep  pustular  syphiloderm  is  a  late  manifesta- 
tion, and  is  associated  with  general  cachexia. 

Syphiloderma  Tuberculosum.  (Syn.  Tubercular  Syphi- 
lide,  Syphilis  Cutanea  Tuberculosa.) — The  tubercular  syphi- 
loderm is  a  late  manifestation,  sometimes  occurring  years 
after  infection,  and  often  in  such  cases,  especially  in  women, 
it  is  impossible  to  get  a  history  of  any  intervening  lesions. 
It  is  one  of  the  most  frequent  of  the  syphilodermata.  As 
ordinarily  encountered,  the  tubercles  appear  in  limited 
numbers,  occur  in  groups,  and  occupy  certain  localized 
regions.  The  lesions  are  of  brownish-red  color,  of  semi- 
globular  shape,  circular  outline,  and  of  firm  consistence. 
In  size  they  vary  from  a  pea  to  a  bean  or  even  a  hazelnut, 
and  correspond  in  many  respects  to  the  large  papules 
already  described. 

The  tubercular  syphiloderm  is  particularly  apt  to  attack 
the  face,  the  back,  and  the  neighborhood  of  the  joints. 
When  an  early  precocious  manifestation,  the  whole  body 
may  be  involved,  but  the  more  remote  the  infection  the 
more  apt  is  the  eruption  to  consist  of  a  few  or  a  single  group 
of  tubercles.  These  groups  may  present  different  con- 
figurations; for  example,  according  to  the  stage  of  evolu- 
tion, there  may  be  present  clusters  of  tubercles  with 
crescentic  edges,  or  a  ring  may  be  formed  by  the  method  of 
development  of  the  lesions,  or  the  eruption  will  assume  a 
serpiginous  character,  as  a  result  of  central  absorption,  or 
by  coalescence  of  several  groups. 

The  tubercular  syphiloderm  runs  a  chronic  course,  and, 
untreated,  may  persist  for  an  indefinite  period.  It  may 
terminate  either  by  resolution  or  ulceration.  In  the  former 
event  the  skin  is  left  depressed,  pigmented,  and  sometimes 
somewhat  scaly,  but  atrophic  changes  may  often  be  pre- 
vented by  timely  treatment.  When  ulceration  occurs  it 
is  rarely  general,  but  here  and  there  a  tubercle  breaks  down 
and  exhibits  a  small,  rounded,  punched-out  ulcer,  usually 
situated  in  the  periphery  of  the  patch,  and  covered  by 
crusts.  By  the  breaking  down  of  all  the  tubercles  in  a 
patch  the  individual  ulcers  may  unite  to  form  one  large 


296  NEW  GROWTHS 

ulceration.  This  syphiloderm  may  also  undergo  the  pap- 
illomatous  transformation,  producing  the  so-called  fram- 
besia  syphilitica,  or  syphilis  cutanea  papillomatosa. 

The  tubercular  syphiloderm  is  to  be  distinguished  from 
lupus  vulgaris,  leprosy,  and  epithelioma.  (See  those  dis- 
eases.) 

Syphiloderma  Gummatosum.  (Syn.  Gmnmatous  Syphi- 
lide,  Syphilis  Cutanea  Gummatosa.) — Gummata  occur  late  in 
syphilis  and  are  most  commonly  situated  upon  the  scalp, 
forehead,  buttocks,  about  the  joints,  and  where  the  con- 
nective tissue  is  loose  and  abundant.  Only  one  or  two 
tumors  are  usually  to  be  noted;  exceptionally  the  growths 
may  be  numerous.  The  growth  makes  its  appearance 
in  the  tissues  as  a  small  pea-sized,  firm,  circumscribed 
nodule,  which  gradually  increases  in  size,  attaining  the 
diameter  of  a  walnut  or  forming  even  larger  deposits.  The 
overlying  skin,  at  first  normal  in  color,  finally  becomes 
encroached  upon  and  assumes  a  reddish  hue,  and  the 
gumma  will  feel  soft  and  doughy  to  the  touch.  Gummata 
may  disappear  by  absorption,  or  else  ulceration  occurs  and 
leaves  in  its  wake  a  deep,  clean-cut  ulcer  that  secretes  a 
bloody,  fetid  pus.  Healing  is  often  slow  and  may  be  further 
delayed  by  various  accidents,  such  as  gangrene,  phagedena, 
etc.  Ulceration  may  also  extend  deeply  and  involve  the 
bones  in  a  necrotic  process,  and  in  the  end  produce  great 
deformity.  This  syphiloderm  should  be  differentiated 
from  fatty  and  fibrous  tumors,  from  erythema  nodosum, 
abscesses,  and  furuncles.  Sometimes  the  gummatou.s  infil- 
tration, instead  of  being  circumscribed,  appears  as  a  large, 
palm-sized  area  which  is  not  sharply  defined  at  the  borders. 

Syphiloderma  Bullosum.  (Syn.  Bullous  Syphilide,  Syphi- 
lis Cutanea  Bullosa.) — The  bullous  syphilide,  if  it  be  proper!  \ 
distinguished  from  certain  forms  of  pustular  lesions,  m;iy 
be  regarded  as  a  rare  symptom  in  adults,  and  it  is  said  to 
occur  for  the  most  part  in  cachectic  subjects.  On  the  other 
hand,  as  is  well  known,  it  is  not  uncommon  in  hereditarily 
affected  children.  The  bulla?  vary  much  in  size,  have  clear 
contents  in  the  beginning  that  gradually  become  purulent, 


THE  SYPHILODERMATA  297 

and  the  effused  pus  dries  into  thick,  greenish-black, 
adherent  crusts,  sometimes  taking  on  the  rupial  arrange- 
ment, in  which  case  the  underlying  ulceration  is  profound. 

Bacteriology. — Schaudinn  and  Hoffman,  in  May  of  1905, 
announced  the  discovery  of  the  Spirochfeta  pallida  as  the 
exciting  agent  of  syphilis.  Its  presence  has  been  estab- 
lished by  many  other  observers  in  the  fluids  expressed  from 
primary  and  secondary  lesions  in  the  tissues  and  in  the 
blood  of  syphilitics,  and  in  hereditary  cases.  Metchnikoff 
and  Roux  found  it  in  their  successful  inoculations  in 
orangs  and  chimpanzees. 

Prognosis. — The  prognosis  of  the  syphilodermata  neces- 
sarily involves  the  future  of  the  disease  as  a  whole.  The 
various  phases  of  this  question  cannot  be  discussed  here; 
but  it  may  be  said  that  the  disease  is  not  the  hopelessly 
incurable  malady  that  it  is  popularly  supposed  to  be — on 
the  contrary,  under  modern  methods  of  treatment,  hygienic 
and  specific,  the  outlook  is  far  from  gloomy,  and  while 
from  many  causes  a  considerable  number  of  syphilitics 
go  from  bad  to  worse,  a  still  larger  proportion  apparently 
recover. 

Treatment. — The  treatment  of  the  syphilodermata  is 
mainly  constitutional,  being  directed  to  the  systemic  con- 
dition upon  which  the  cutaneous  expression  of  the  disease 
depends,  but  at  the  same  time  well-directed  local  measures 
are  often  of  great  value  in  expediting  a  cure.  Mercury  and 
the  iodides  are  specific  remedies  in  syphilis,  and,  employed 
in  a  judicious  manner,  are  absolutely  indispensable;  but 
here,  as  elsewhere,  the  general  state  of  the  patient,  as  well 
as  the  name  of  his  disease,  must  be  taken  into  consideration 
to  obtain  the  most  satisfactory  results. 

Before  beginning  the  constitutional  treatment,  the  patient 
should  receive  definite  instruction  in  matters  of  personal 
hygiene,  such,  for  example,  as  the  can;  of  the  skin  in  the 
way  of  bathing,  and  the  frequent  use  of  the  tooth-brush 
and  of  some  appropriate  mouth-wash;  it  is  also  generally 
advisable  to  have  the  teeth  put  in  good  condition  by  the 
dentist.  In  our  judgment  tobacco  in  any  form  should  be 


298  NEW  GROWTHS 

prohibited  absolutely,  and  we  are  sure  that  the  patient  is 
much  better  off  without  alcohol. 

A  patient  should  never  be  put  on  specific  treatment 
until  the  diagnosis  of  syphilis  is  absolutely  established, 
and  we  believe  we  can  never  be  quite  certain  of  that  fact, 
until  the  period  of  the  general  manifestations  of  the  dis- 
ease. Violation  of  this  cardinal  rule  leads  to  an  infinite 
amount  of  mischief. 

The  only  trustworthy  way  of  treating  syphilis  is  with 
mercury  and  the  iodine  preparations. 

There  are  a  number  of  different  methods  of  introducing 
mercury  into  the  system,  namely,  by  the  mouth,  by  inunc- 
tion, by  fumigation,  and  by  hypodermic  injection;  and 
each  undoubtedly  has  its  place  in  selected  cases.  The 
most  convenient  and  practicable  avenue  is  by  the  mouth, 
and  although  at  times  attended  by  certain  drawbacks, 
ordinary  skill  and  care  will  readily  obviate  these  incon- 
veniences. Among  the  preparations  commonly  employed 
may  be  mentioned  the  protiodide,  the  gray  powder,  blue 
mass,  corrosive  sublimate,  and  the  tannate. 

In  this  country,  the  protiodide  is  the  favorite  salt  with 
most  physicians.  It  may  be  given  in  pill  form,  combined 
or  not  with  conium  or  opium,  or  as  a  tablet  triturate.  The 
sugar  or  gelatin-coated  pills  are  also  suitable.  Usually, 
from  \  to  ^  gr.  of  the  protiodide  will  suffice,  but  if  a  more 
decided  impression  is  demanded  this  quantity  may  be 
increased  to  2  or  even  3  gr.  a  day,  but  generally  under  such 
circumstances  some  other  preparation  or  mode  of  adminis- 
tration may  be  selected  with  advantage.  The  golden  rule 
is,  we  think,  to  give  only  such  amounts  of  the  drug  as  will 
do  the  work  in  hand  with  the  least  detriment  to  the  patient. 
In  nearly  all  cases  of  early  syphilis,  iron,  or  iron  and  quinine 
should  be  combined  with  the  mercury. 

A  most  excellent  formula  suggested  by  Dr.  R.  W.  Taylor 
is  as  follows : 

1$ — Hydrarg.  protiodidi gr.  vj-vij 

Ferri  et  quinine  citratis 5jss 

Ext.  hyoscyami gr.  vj — M. 

Div.  in  pil.  xxx. 

S. — One  pill  three  times  a  day. 


THE  SYPHILODERMATA  299 

Sometimes  it  is  more  convenient  to  give  the  tonic  sepa- 
rately from  the  mercury,  so  that  the  amount  of  the  latter 
may  be  increased  or  diminished  as  required.  So  soon  as 
the  patient's  general  health  improves,  although  very  often 
it  is  not  visibly  affected,  the  tonic  may  be  dropped  and  the 
mercury  given  alone. 

Should  the  mercury  produce  any  griping  or  diarrhea, 
some  carminative  or  a  little  paregoric  may  be  given  from 
time  to  time.  Except  in  the  most  urgent  cases  it  is  not 
desirable  or  necessary  to  produce  the  toxic  effects  of  the 
drug,  but  in  all  cases  the  condition  of  the  mouth  should  be 
constantly  noted  and  as  soon  as  there  is  any  tenderness  of 
the  gums  or  other  evidences  of  salivation,  the  remedy 
should  be  given  in  diminished  doses  or  discontinued  for  a 
brief  period. 

It  is  a  habit  with  some  physicians  to  change  the  prepa- 
ration of  mercury  from  time  to  time,  either  from  a  belief 
that  certain  combinations  are  useful  for  certain  periods  in 
the  disease,  or  that  in  this  way  better  results  may  be 
obtained.  We  are,  however,  in  the  habit  of  giving  some 
one  suitable  salt  throughout;  such  as  the  protiodide,  for 
example,  and  if  a  change  is  required,  to  make  it  in  the 
direction  of  inunction  or  hypodermic  injection. 

The  inunction  method  is  a  most  valuable  way  of  giving 
mercury,  and  while  it  may  be  used  exclusively,  we  believe 
it  is  better  to  employ  it  in  alternation  with  mercury  by 
the  mouth.  The  preparation  usually  recommended  is  the 
freshly  prepared  unguentum  hydrargyri,  50  per  cent, 
strength,  put  up  in  capsules  or  oiled  papers  containing 
from  50  to  60  gr.  White  and  Martin  prefer  the  following 
prescription: 

ty — Vug.  hydrargyri, 

Ung.  petrolii  carbolat aa     3j 

M.  et  div.  in  part.,  No.  xvi. 
S. — Use  one  portion  at  bedtime. 

Before  beginning  the  rubbings,  the  patinet  should  take 
a  hot  bath  followed  by  brisk  toweling,  or,  if  this  is  imprac- 
ticable, the  part  to  be  anointed  should  be  well  washed  with 


300  NEW  GROWTHS 

soap  and  water,  after  which  it  may  be  mopped  with  a  2  or  3 
per  cent,  carbolic  solution  (Taylor). 

The  ointment  should  be  well  worked  in  with  the  palms, 
and  from  twenty  to  thirty  minutes  should  be  occupied  in 
this  process.  Since  the  skin  would  soon  react  to  long- 
continued  applications  in  one  place,  different  portions  of  the 
body  must  be  selected  for  the  successive  inunctions,  taking 
care  to  avoid  hairy  regions.  The  parts  of  the  body  suitable 
for  this  purpose  are  the  inner  surfaces  of  the  thighs,  the 
sides  of  the  thorax,  the  inner  surfaces  of  the  arms,  the 
flanks,  the  lower  part  of  the  leg,  etc. 

As  a  rule,  the  same  underclothing  should  be  worn  for 
several  days  while  undergoing  the  treatment,  but  if  this  be 
objected  to,  a  bath  may  be  taken  in  the  morning,  clean 
linen  used  in  the  day  and  the  old  garments  slept  in  at  night. 

On  the  evening  of  the  sixth  day,  under  any  circum- 
stances, the  patient  should  suspend  the  inunctions,  take  a 
hot  bath,  and  begin  again  on  the  seventh  day.  As  a  rule, 
we  believe  it  is  well  to  stop  the  rubbings  for  a  few  days  after 
a  three  weeks'  course,  but  the  total  length  of  the  inunc- 
tion cure  will  depend  upon  the  condition  of  the  patient's 
general  health  and  the  influence  of  the  treatment  on  the 
specific  lesions. 

Among  the  advantages  of  this  inunction  method  may  be 
mentioned,  first,  its  distinct  therapeutic  value,  secondly, 
the  absence  of  gastric  disturbance,  and,  thirdly,  that  simul- 
taneously other  treatment,  tonic  or  specific,  such  as  the 
iodides,  may  be  given  by  the  stomach. 

Among  the  disadvantages  may  be  mentioned  the  extreme 
unpleasantness  of  the  method,  the  difficulty  of  getting  the 
inunctions  properly  done,  the  great  liability  to  stomatitis, 
and  the  possibility  of  setting  up  a  mercurial  dermatitis 
which  may  become  generalized;  this  latter  complication 
is,  however,  very  unusual. 

The  hypodermic  injection  of  mercury  is  indicated  when  a 
speedy  effect  is  urgently  demanded,  or  where  other  methods 
of  administration  are  contra-indicated  or  fail  of  effect. 

As  an  exclusive  method  of  treatment  hypodermic  injec- 


THE  SYPHILODERMATA  301 

tions  have  not  met  with  much  favor  in  this  country,  in  spite 
of  the  approval  of  such  excellent  authorities  as  Klotz  and 
others. 

The  technique  of  the  operation  is  very  important. 

The  syringe  should  be  of  hard  rubber,  or,  preferably,  of 
glass,  having  a  tough  needle  sufficiently  long  to  allow  the 
medicament  to  be  deposited  in  the  subcutaneous  tissue, 
or  into  the  muscle,  according  to  the  preference  of  the 
physician.  All  preparations  for  injection  should  be  taken 
with  a  view  to  complete  asepsis. 

The  hands  of  the  physician  having  been  cleansed  after 
the  approved  surgical  manner,  the  site  for  injection  should 
be  wiped  off  with  alcohol,  or  otherwise  rendered  sterile. 
The  best  locality  for  hypodermic  injection  is  the  depression 
just  posterior  to  the  great  trochanter,  and  next,  the  sub- 
scapular  region  near  the  spine.  The  suspensions  of 
insoluble  salts  should  be  thrown  into  the  gluteal  muscles, 
entering  the  needle  at  a  point  between  the  ischial  tuberosity 
and  the  trochanter,  and  pushing,  perpendicularly,  into  the 
muscle.  Having  expelled  all  air  from  the  syringe,  the 
needle  is  plunged  into  the  tissue.  If  an  insoluble  salt  is 
used,  the  barrel  should  be  removed  in  order  to  see  if  a  vein 
has  been  entered,  in  which  case  blood  will  issue  from  the 
open  end  of  the  needle.  By  this  procedure,  the  chance  of 
embolism  may  be  averted. 

The  barrel  is  then  replaced  and  the  injection  made. 
The  puncture  should  be  sealed  with  collodion. 

Care  should  be  taken  at  all  times  to  introduce  the  needle 
deeply  enough,  whether  it  be  into  the  subcutaneous  cellular 
tissue  or  into  the  muscle.  Gentle  massage  hastens  the 
disappearance  of  the  resulting  tumefaction  and  lessens  the 
danger  of  a  painful  nodosity.  A  great  number  of  prepa- 
rations of  mercury  have  been  recommended  for  subcu- 
taneous injections,  of  which  only  a  few  will  be  mentioned 
here. 

Soluble  Mercurial  Salts. — So  far  as  the  soluble  salts  are 
concerned,  corrosive1  sublimate  will  meet  all  the  require- 
ments with  the  least  danger  to  the  patient.  It  is  best  to 


302  NEW  GROWTHS 

have  the  solution  freshly  made  with  distilled  water,  and 
the  prescription  so  calculated  that  20  or  40  minims  will 
contain  ^  gr.  This  is  the  usual  initial  dose,  although  it 
may  be  increased  to  \  or  ^  gr.  Taylor  regards  \  gr.  as 
the  proper  dose.  The  injections  may  be  made  daily,  or  on 
alternate  days,  but  both  the  frequency  of  the  injections 
and  the  amount  of  mercury  administered  will  depend  upon 
the  case  in  hand. 

Insoluble  Salts. — The  insoluble  salts  most  generally  em- 
ployed are  calomel,  metallic  mercury  given  in  the  form 
of  gray  oil,  salicylate  of  mercury,  and  the  yellow  oxide. 
The  insoluble  salts  are,  as  a  rule,  injected  once  a  week. 
(See  list  of  formulae  below.) 

The  question  of  the  value  of  subcutaneous  injections  of 
mercury  in  the  treatment  of  syphilis  has  been  so  thor- 
oughly threshed  over  that  it  would  be  a  waste  of  time  to 
consider  it  now.1  Intramuscular  injections  are  rarely 
required  in  the  treatment  of  the  skin  lesions  of  syphilis, 
but  constitute  a  precious  resource  in  dealing  with  threaten- 
ing brain  and  cord  lesions.  With  an  improved  technique, 
and  a  better  understanding  of  the  proper  dosage,  the 
method  is  free  from  the  many  accidents  that  were  so 
common  in  earlier  years. 

There  are  various  other  methods  of  introducing  mercury 
into  the  system,  which  have  been  advocated  from  time  to 
time,  but  which,  while  accomplishing  this  object  to  a 
greater  or  less  degree,  can  in  no  way  take  the  place  of  the 
more  usual  measures  and  should  not  be  relied  upon  in  the 
routine  treatment  of  syphilis.  Briefly  stated,  these  methods 
are,  by  intravenous  injection,  by  fumigation,2  which  con- 

1  This  question  is  exhaustively  -discussed  in   Fournier's  Treatment 
of  Syphilis  now  translated  (Rebman  Company,  New  York),  and  in 
White    and   Martin's  Genito-urinary  and  Venereal  Diseases   (Lip- 
pincott,  Philadelphia) . 

2  Fumigation,  while  not  to  be  depended  upon  exclusively  in  the 
routine  treatment  of  syphilis,  is  of  undoubted  value  in  chronic  scaling 
and  ulcerative  lesions.     The  mercurial  vapor  is  generated  from  a 
Lee  lamp  on  which  has  been  placed  20  gr.  of   calomel  and  40  of 
cinnabar  (Taylor).    The  clothes  are  entirely  removed  and  the  patient 
is  seated  over  the  apparatus,  covered  with  blankets  up  to  the  neck. 
Each  bath  lasts  from  ten  to  twenty  minutes.    Baths  may  be  taken 
every  other  day,  and  later,  if  required,  daily. 


THE  SYPHILODERMATA  303 

sists  in  the  vaporization  of  calomel,  the  administration  of 
mercurial  baths,  the  application  of  mercurial  plasters,  and 
the  wearing  of  mercurial  flannels  (mercolint). 

The  iodine  compounds  are  used  by  some  physicians  in 
the  early  stages  of  syphilis,  and  there  is  no  doubt  that  they 
give  much  relief  to  the  arthritic  pains  and  neuralgias  of 
that  period,  but,  as  a  rule,  this  method  of  medication  should 
be  reserved  for  the  second  year,  and  then  administered  in 
conjunction  with  mercury.  However,  there  are,  neces- 
sarily, exceptions  to  this  rule,  as  in  the  case  of  precocious 
syphilis,  etc.  Of  the  enormous  value  of  the  iodides,  and 
preeminently  of  the  iodide  of  potassium,  in  late  and 
tertiary  lesions,  there  is  no  doubt  that  even  here  mercury 
should  be  prescribed  at  the  same  time  and  kept  up  for  a 
season  after  the  discontinuance  of  the  iodide. 

Owing  to  the  intolerance  many  persons  show  for  the 
iodide  of  potassium,  other  iodine  salts  have  been  recom- 
mended at  various  times,  but  with  the  exception  of  the 
iodide  of  sodium,  which  should  be  given  in  somewhat 
larger  doses  than  the  iodide  of  potassium,  these  substitutes 
are  not  to  be  relied  upon.1 

The  usual  dose  of  the  iodide  of  potassium  is  from  5  to 
20  gr.,  three  times  a  day,  but  this  quantity  may  be  greatly 
exceeded.2 

Our  own  experience  inclines  us  to  relatively  small  doses, 
and  we  are  firmly  of  the  opinion  that  if  the  drug  is  given 
with  tonics  and  stomachics  the  curative  effect  will  be  much 

1  Leistikow  states  that  inunctions  of  iodinvasogen  (6  to  10  per  cent.) 
may  be  depended  upon  when  this  drug  cannot    be  taken   by  the 
mouth.    Forty-five  grains  may  be  rubbed  in  daily  for  three  weeks, 
giving  one  inunction  daily.    lodipin  by  the  mouth  or  subcutaneously 
is  also  recommended.    (See  formulae.) 

2  Fournier  insists  that  small  doses  of  iodide  appear  to  be  particu- 
larly harmful,  that  is,  that  they  are  more  frequently  followed  by 
severe  signs  of  intoxication.    As  an  initial  dose  he  gives  an  adult  man 
30  gr.  a  day,  and  a  woman  15  to  20  gr.    Subsequently  this  daily  dose 
is  raised  to  45  gr.  and  then  to  60  gr.  or  more  if   necessary.    On  the 
other  hand,  he  is  opposed  to  the  colossal  doses  (100  gr.  or  more) 
that  are  sometimes  administered,  basing  his  opposition  on  the  fact 
of  their  uselessness. 


304  NEW  GROWTHS 

more  prompt  than  with  large  quantities  of  the  iodide 
administered  alone.  (See  formula  below.) 

The  best  time  to  give  the  iodide  is  directly  after  meals, 
and  well  diluted.  If  for  any  reason  it  is  not  desired  to 
combine  it  with  other  drugs,  it  may  be  administered  in 
syrup  of  sarsparilla,  plain  water,  milk,  Vichy,  essence  of 
pepsin,  or  junket. 

The  so-called  mixed  treatment  consists  in  the  simultane- 
ous administration  of  mercury  and  iodide  of  potassium, 
and  is  held  to  be  of  especial  value  in  tardy  manifestations  of 
the  disease.  A  formula  that  we  have  employed  for  many 
years,  and  which  we  owe  to  the  elder  Bulkley,  is  as  follows: 

1$ — Hydrargyri  protiodidi, gr.  v-x 

Ext.  opii       .      .      . gr.  v 

M.  et  div.  in  pil.  No.  xx. 

S. — One  pill  morning  and  evening. 

1$ — Potassii  iodidi 5ss 

Ferri  et  ammonii  citratis ,~j 

Tr.  nucis  vomica; 3|j 

Aqua; 5jss 

Tr.  cinchona;  comp q.  s.  ad    3iv — M. 

S. — Teaspoonful  in  one-half  glass  of  water  after  meals. 

It  is  absolutely  necessary  that  the  tincture  of  cinchona 
should  be  detannated. 

It  is  often  a  good  plan  to  give  the  patient  in  addition  a 
saturated  solution  of  iodide  of  potassium  (1$ — Potassii 
iodidi,  oj;  aqme  destillatse,  q.  s.  ad  f^j — M.),  so  that 
larger  doses  of  the  salt  may  be  administered  from  time  to 
time  as  may  be  indicated. 

The  two  drugs  may  be  combined  in  the  same  prescription : 

1$ — Hydrargyri  biniodidi  gr.  ss-j 

Potassii  iodidi    . 


Ammonii  iodidi. 
Syr.  aurantii  corticis 
Tr.  aurantii  corticis 
Aqua*  destillatiE 


.)SS 


oj 
q.  s.  ad    3iv  —  M. 


S. — Teaspoonful  well  diluted  in  water  after  meals.        Keyes. 

P^ — Hydrargyri  hichloridi gr.  ij-iv 

Potassii  iodidi oviij 

Syrupi  sarsaparillie  comp Sviij — M. 

S. — Teaspoonful  in  water  after  meals. 


THE  SYPHILODERMATA  305 

Another  formula  of  great  value  is  given  by  Hayden : 

1$ — Hydrargyri  biniodidi gr.  j-ij-iij 

Potassii  iodidi oij-3iv 

Ess.  pepsini .      .      .     5iij 

Aquae q.  s.  ad    Biv — M. 

S. — Teaspoonful  in  one-quarter  glass  of  water  after  meals. 

The  bichloride  of  mercury,  combined  with  the  iodide  of 
potassium,  and  prescribed  in  conjunction  with  a  bitter 
tincture,  or,  in  anemic  subjects,  with  the  tincture  of  the 
chloride  of  iron,  is  a  favorite  prescription  with  many 
syphilographers. 

The  question  of  the  length  of  time  constitutional  treatment 
should  be  kept  up  is  of  much  practical  importance.  So 
far  as  the  administration  of  mercury  is  concerned  we  must 
confess  to  little  confidence  in  the  long-continued,  uninter- 
rupted courses  running  over  years.  In  our  judgment  some 
form  of  the  so-called  interrupted  treatment  is  to  be  pre- 
ferred after  the  first  six  or  twelve  months. 

In  a  fresh  case  of  syphilis  a  more  decided  impression  can 
be  made  on  the  disease  in  the  first  year  than  at  any  other 
time,  therefore  the  physician  should  take  advantage  of  his 
opportunity,  and,  the  patient's  condition  allowing  it,  push 
the  treatment  with  steadiness  and  vigor.  With  brief 
intervals  of  rest,  it  is  advisable  to  keep  up  the  mercury  for 
at  least  six  months,  and  oftenest  a  year;  at  the  end  of  this 
time  omit  treatment  for  a  month  or  six  weeks,  giving 
tonics  in  the  interval.  At  the  expiration  of  the  allotted 
period  order  a  course  of  inunction  or  put  the  patient  again 
on  the  protiodide  or  other  suitable  mercurial.  Henceforth, 
that  is  for  the  next  year  and  one-half,  the  periods  of  active 
treatment  are  gradually  decreased  in  length  and  the  periods 
of  rest  increased. 

Usually  in  the  beginning  of  the  second  year  the  iodide 
of  potassium  is  added  to  the  mercury,  constituting  the 
mixed  treatment.  Of  course,  it  will  be  understood  that  the 
dose  and  method  of  mercurial  treatment,  the  time  for  the 
addition  of  the  iodides,  the  length  of  time  occupied  in 
active  medication,  or  in  abstention  from  medication,  will 
depend  largely  upon  the  case  in  hand. 
20 


306  ^EW  GROWTHS 

Finally,  we  believe  that  even  in  the  absence  of  all  symp- 
toms of  the  disease  the  patient  should  follow  up  the  period 
of  active  treatment,  with  at  least  two  courses  of  specific 
medication  during  the  year,  for  three  or  four  years  longer. 

Experience  has  forced  the  conviction  upon  us  that  treat- 
ment, and  much  treatment,  offers  the  best  guarantee  for  the 
patient's  future  welfare. 

In  this  place  it  is  opportune  to  call  attention  to  the  fact 
that  in  daily  practice  we  often  meet  with  apparently 
intractable  cases  of  late  syphilis,  which  persist  or  repeatedly 
relapse  in  spite  of  the  most  heroic  specific  treatment.  In 
such  cases  absolute  omission  of  all  antisyphilitic  medica- 
tion for  a  season,  or  the  combination  with  specific  drugs 
of  appropriate  tonics  and  stomachics,  especially  iron  and 
nux  vomica,  will  soon  bring  about  satisfactory  results. 
In  other  words,  it  is  altogether  too  common  a  habit  to  give 
mercury  and  the  iodides  in  a  routine  way  in  syphilis,  and 
to  ignore  the  patient  who  happens  to  have  the  disease. 

ADDITIONAL  PRESCRIPTIONS. 

!$ — Hydrarg.  tannici gr.  xv-xxx 

Quinina?  sulphatis 5j 

Ext.  hyoscyami gr.  vj 

Div.  in  pil.  No.  xxx. 

S. — One  pill  three  times  a  day.  Hayden. 

1^ — Hydrarg.  cum  creta gr.  xxxvj 

Quininse  sulph gr.  liv 

Pulv.  opii gr.  vj 

Ext.  quassia* q.  s. — M. 

Ft.  pil.  No.  xxxvi. 

S. — One  pill  after  meals  three  times  a  day.  \Yhitla. 

1^ — Hydrarg.  chlor.  corrosiv gr.  j-ij 

Potassii  iodidi    .      .  5ij-iv 

Ferri  et  ammon.  cit.  5j 

Tr.  nucis  vomicae    .  oij 

Tr.  cinchona?  comp.  5ss-oij 

Aqua}      ....  q.  s.  ad  5iv — M. 

S. — Teaspoonful  in  water  after  meals  Rulklry. 


THE  SYPHILODERMATA  307 

1^ — Mass,  hydrarg gr.  xl 

Ferri  sulphatis  exsiccat 3j 

Ext.  opii gr.  v — M. 

Div.  in  pil.  No.  xx. 

S. — One  pill  twice  to  four  times  a  day.  Bumstead. 


1$  —  Hydrarg.  chlor.  corrosiv  .......     gr.  j-ij 

Tr.  ferri  chloridi, 

Acidi  hydrochlorici  diluti  .....   aa     3ij-iv 

Syr.  aurantii  flor  .........      5ij 

Aquae      ........      q.  s.  ad     Sviij—  M. 

S.—  Teaspoonful  in  wineglassful  of  water  after  each  meal. 

Hyde  and  Montgomery. 

rj  —  Fl.  ext.  erythroxylon  coca?       .....      5ij 

Tr.  gentian,  comp., 

Tr.  cinchon.  comp  .......   aa     5j 

Elix.  calisayre    .........      §iv  —  M. 

S.  —  One  tablespoonful  in  wineglassful  of  water,  three  times  a  day, 
oiu>  hour  after  meals.    As  an  adjuvant  in  the  treatment  of  syphilis. 

Taylor. 

1$  —  Strychnine  sulph  .........      gr.  ss 

Calcis  glycerophosphat       ......      5iij 

A<|iuc       ........      q.  s.  ad     §iv  —  M. 

S.  —  Shake.    Teaspoonful  before  meals  in  water.    As  a  tonic. 

Greene. 

1^  —  Hydrarg.  chlor.  corrosivi    ......      gr.  iv  T8o 

Sodii  chlor  ...........      gr.  iijss 

Aqua?  destillatfe      ........      3j  —  M. 

S.  —  One  per  cent,  solution  of  mercuric  chloride.     10  to  30  minims 
hypodermically.  \Yhite  and  Martin. 

1$  —  Ilydrarg.  oxidi  flav  ........  gr.  xv 

Acaciio    ...........  gr.  iv 

Aqua>  dcstillatio       ........  3j  —  M. 

S.  —  Fifteen  minims  at  an  injection. 


1^  —  Calomelanos       ......... 

Glycerini  puri     ......... 

Aqua-  destillataj        ........      5ij  —  M. 

S.  —  Dose:  From  5  to  15  minims  to  be  repeated  at  intervals  of 
from  five  to  fifteen  days.  This  can  bo  sterilized  by  placing  the  light  1  y 
corked  bottle  in  water  up  to  the  neck,  raising  the  temperature  up  to 
the  boiling  point  and  keeping  it  there  for  an  hour.  Gottlin'l. 


308  NEW  GROWTHS 

R< — Mercury  (by  weight) 5j 

Anhydrous  lanolin  (by  weight)      .      .      .  5iv 

Liq.  paraffin,  carbolized  to  2%  (by  vol.)  to  3x 

S. — Fifteen  minims  is  a  full  dose.  Lambkin. 

1$ — Hydrarg.  salicylic! gr.  Ixxv 

Olei  paraffin! 5j~5v$ — M. 

S. — Inject  15  minims.  Ravold. 

R- — Xerofprmi gr.  xxiv-xlviij 

Vaselini 5ij 

Lanolini 5vj — M. 

S. — Spread  on  patent  lint.    For  syphilitic  ulcerations. 

1$ — Hydrargyri     . oij 

Olei  terebinthinse n\xx 

Cerae  flavae gr.  xx 

Resinae gr.  xl 

Styracis 5j 

Empl.  plumbi 5j — M. 

S. — Emplastrum  de  Vigo,  used  by  the  French  for  the  same  pur- 
pose as  the  mercurial  plaster  of  Neumann. 

R< — Hydrarg.  ammoniati gr.  xx-xxx 

Zinci  oxidi 3ss 

Pulv.  amyli 5ij 

Vaselini 5j — M. 

S. — For  papular  and  pustular  eruptions. 

R- — Hydrargyri 5iv 

Olei  terebinthinae 5ij 

Cerae  flavae 5uj 

Empl.  plumbi Sjss — M. 

S. — Spread  on  cotton  cloth.    To  resolve  nodules  of  syphilis  and  to 

stimulate  ulcerations.  Neumann. 

1$ — Resorcini gr.  xxx 

Adipis  benz 5j — M. 

S. — Local  use.     For  the  erythema  of  syphilis  associated  with 

seborrhea.  Groonc. 

R- — Olei  rosae  geranii gtt.  viij 

Quininae  bisulph gr.  xx 

Tr.  cantharidis §v 

Tr.  jaborandi 3j 

Aqua;  picis q.  s.  ad  3 viij — M. 

S. — Rub  into  scalp  in  syphilitic  alopecia.  Greene. 


THE  SYPHILODERMATA  309 

Judicious  local  treatment  will  often  hasten  the  disappear- 
ance of  disfiguring  or  annoying  cutaneous  lesions.  Cer- 
tain of  the  earlier  and  more  superficial  manifestations 
require  nothing,  but  papular  lesions  on  the  face  are  much 
helped  by  ointments  of  the  white  precipitate,  consisting  of 
30  to  60  gr.  of  the  medicament  to  1  oz.  of  lard  or  cold 
cream.  Oleate  of  mercury  in  from  5  to  20  per  cent,  strength 
is  also  useful  on  covered  surfaces.  We  often  use  Unna's 
formula  of  1  drachm  of  ichthyol,  \  oz.  of  ung.  hydrarg., 
and  3  drachms  of  lanolin.  Squamous  patches  on  the 
palms  and  soles  are  much  helped  by  the  compound 
salicylated  soap  plaster.  The  x-rays  are  also  valuable  in 
these  cases.  Moist  papules  are  best  treated  by  absolute 
cleanliness,  and  contiguous  skin  surfaces  should  be  kept 
apart  by  interposition  of  absorbent  cotton.  The  lesions 
may  be  dusted  with  dry  calomel,  or,  if  obstinate,  occa- 
sionally touched  with  the  nitrate  of  silver  stick,  or  the  acid 
nitrate  of  mercury. 

In  ulcerated  lesions  generally,  the  crusts  are  to  be  removed 
and  the  ulcers  dressed  with  aristol  or  some  other  similar 
powder.  Syphilitic  tubercles  usually  disappear  promptly 
under  internal  treatment,  but  it  is  sometimes  advisable  to 
apply  local  remedies  simultaneously.  The  salicylated  soap 
plaster,  spread  on  cloth,  is  excellent  for  this  purpose,  as  is 
also  the  emplastrum  hydrargyri  of  the  German  pharma- 
copeia. Mercurial  vapor  baths  and  baths  of  corrosive 
sublimate  are  also  excellent  means  for  the  removal  of 
local  lesions. 

Cutaneous  Eruptions  of  Hereditary  Syphilis.— The 
lesions  of  the  skin  due  to  inherited  syphilis  present  pecu- 
liarities sufficiently  marked  to  warrant  separate  considera- 
tion. On  this  organ  the  first  observable  symptoms  of  the 
disease  are  apt  to  fall. 

Although  syphilitic  children  may  present  specific  erup- 
tions at  birth,  or,  indeed,  during  intra-uterine  life,  it  is  a 
matter  of  common  experience  that  they  often  appear 
comparatively  healthy  when  first  born.  This  condition  of 
apparent  well-being  rarely  continues  beyond  the  first  six 


310  NEW  GROWTHS 

weeks,  and  even  before  any  disturbances  of  the  skin  are 
observed  the  child  will  often  present  marked  evidences  of 
syphilitic  cachexia. 

Among  the  more  prominent  general  symptoms  are  to  be 
noted  the  characteristic  snuffling,  the  sallow  skin,  and  the 
striking  senile  appearance  of  infants  thus  affected.  The 
principal  eruptions  seen  in  connection  with  hereditary 
syphilis  are  the  following:1 

The  erythematous  syphilodenn,  or  syphilide,  is  the  com- 
monest and  usually  the  earliest  hereditary  eruption,  some- 
times being  present  at  birth,  but  rarely  developing 
after  the  third  month.  The  rash  generally  first  appears 
upon  the  belly  and  lower  part  of  the  chest,  and  spreads 
from  those  situations  to  other  portions  of  the  body,  limbs, 
and  face.  The  lesions,  which  are  about  the  size  of  the 
finger-nail,  and  of  an  ovalish  contour,  are  of  a  somewhat 
bright  red  in  the  beginning,  and  may  be  effaced  by  pressure, 
but  later  on  they  assume  a  coppery  color.  The  macules 
often  coalesce  to  form  extensive  non-elevated  patches. 
When  the  erythema  occurs  in  large  sheets  a  common 
situation  for  its  development  is  about  the  neck  and  but- 
tocks. In  these  latter  localities  it  simulates  ordinary 
intertrigo  very  closely,  except  that  about  the  anal  and 
genital  regions  it  travels  beyond  the  parts  covered  by  the 
diaper,  and  runs  down  the  backs  of  the  legs  to  the  heels. 
A  few  outlying  macules  or  maculopapules  may  generally 
be  discovered.  It  is  not  uncommon  to  find  the  palms  and 
soles  red,  wrinkled,  and  desquamating.  The  bistre  tint  so 
often  seen  in  the  face  is  due  to  the  pigmentation  left  by  a 
preceding  roseola.  The  erythematous  patches  in  certain 
situations  may,  as  the  result  of  traumatism,  become  fis- 
sured, covered  with  crusts,  or  become  converted  into  mu- 
cous patches.  The  diagnosis  is  not  difficult  if  the  general 
symptoms  and  the  special  features  mentioned  above  are 
carefully  considered. 

1  It  must  be  remembered  that,  as  in  acquired  syphilis,  certain  of 
these  eruptions  may  coexist  or  be  evolved  one  from  the  other,  etc. 


THE  SYPHILODEBMATA  311 

The  papular  syphiloderm  is  an  early  symptom  of  the 
disease.  It  may  exist  alone  or  be  present  in  connection 
with  the  erythematous  eruption.  The  discrete,  flat  papule 
is  the  most  frequent  type;  the  small,  acuminate  papule, 
according  to  Taylor,  being  unusual,  except  as  a  relapsing 
lesion,  or  else  late  in  the  disease.  The  papules  have  the 
peculiar  syphilitic  tint  and  may  be  smooth,  although  in 
certain  situations,  e.  g.,  palms  and  soles,  desquamation  is  a 
marked  feature.  About  the  anus  and  genitals  and  at  the 
corners  of  the  mouth,  as  well  as  in  other  regions  subject 
to  pressure  or  irritating  influences,  the  papular  lesion  be- 
comes transformed  into  the  mucous  patch,  which  does  not 
differ  materially  from  that  observed  in  the  acquired  disease. 
Excoriations,  fissures,  and  consequent  loss  of  substance 
are  not  infrequent,  and  produce  characteristic  scars,  espe- 
cially about  the  nose  and  angles  of  the  mouth. 

The  vesicular  syphiloderm  as  an  independent  type  is 
exceedingly  rare,  and  is  usually  associated  with  other  forms 
of  eruption,  or  it  may  develop  upon  the  papular  lesion. 

The  pustular  syphiloderm  may  occur  as  the  only  mani- 
festation, or  appear  in  connection  with  other  eruptions; 
or  it  may  develop  from  papular  or  vesicular  lesions.  Occur- 
ring early  it  has  usually  a  grave  significance.  The  head, 
face,  palms,  soles,  trunk,  and  limbs  may  be  affected,  but  it 
generally  is  more  abundant  on  the  face,  thighs,  and  buttocks. 
On  the  face,  and  particularly  about  the  mouth,  the  pus- 
tules run  together  to  form  crusted  patches,  under  which 
there  is  a  certain  degree  of  ulceration.  Discrete  pustules 
form  also  upon  the  palms  and  soles,  and  in  cachectic 
children  they  form  around  and  under  the  free  border  of  the 
nails. 

Some  authors  describe  a  furuncular  syphiloderm,  which 
may  constitute  the  sole  visible  evidence  of  the  disease. 
Atkinson  looks  upon  this  process  as  related  to  the  tuber- 
cular and  gummatous  infiltration. 

The  bullous  syphiloderm,  or  the  so-called  syphilitic 
pemphigus,  is  an  early  and  very  grave  expression  of  the 
hereditary  affection.  It  is  frequent.  It  is  not  common 


312  NEW  GROWTHS 

upon  the  face  and  trunk,  but  seeks  by  predilection  the 
palms  and  soles,  whence  it  may  travel  up  the  forearms  or 
legs. 

The  bullse  develop  on  dusky  reddish  areas  as  small 
vesicular,  or  sometimes  pustular,  elevations  of  the  epi- 
dermis, and  rapidly  go  on  to  form  pea-  or  walnut-sized 
blebs  having  cloudy,  purulent  or  even  bloody  contents. 
They  have  no  uniformity  of  shape  and  may  be  either  tense 
or  flaccid.  According  to  Taylor  they  are  surrounded  by  a 
thickened  rim  of  copper-colored  integument.  Symmetry 
is  the  rule.  The  non-specific  pemphigus  differs  from 
the  bullous  syphiloderm  in  the  fact  that  it  does  not  occur 
on  the  palms  and  soles,  in  the  serous  character  of  the  con- 
tents of  the  blebs,  and  in  the  absence  of  profound  cachexia 
and  other  evidences  of  syphilis;  besides  the  syphilitic 
eruption  does  not  relapse,  and  is  rarely  seen  after  the 
twelfth  week  (Atkinson). 

The  tubercular  syphiloderm  is  rare  in  hereditary  syphilis 
and  generally  occurs  late.  Fournier  states  that  tubercles 
are  mostly  to  be  seen  on  the  face  and  the  anterior  surfaces 
of  the  legs.  Gummata,  when  seen  in  hereditary  syphilis, 
are  usually  late. 

Treatment. — The  treatment  by  inunction,  as  suggested 
by  Sir  Benjamin  Brodie,  undoubtedly  gives  the  best  results 
in  the  majority  of  cases.  Brodie  was  in  the  habit  of 
employing  mercurial  ointment  of  the  strength  of  1  drachm 
to  1  oz.  of  lard,  which  was  spread  over  a  flannel  roller  once  a 
day,  and  bound  around  the  child.  Usually  a  piece  of  equal 
parts  of  unguentum  hydrargyri  and  vaselin  of  the  size  of  a 
hazelnut  may  be  smeared  over  the  flannel  binder  every  day, 
taking  care,  however,  to  wash  the  parts  daily  with  soap  and 
warm  water,  and,  if  irritation  of  the  skin  should  arise,  to 
apply  the  ointment  to  a  different  region.  This  treatment 
should  be  continued  for  some  time  after  all  symptoms  have 
passed  away.  Sometimes  the  condition  of  the  skin,  or 
other  reasons,  render  the  inunction  cure  inadmissible,  in 
which  case  the  drug  may  be  administered  by  the  mouth. 
For  this  purpose  powders  of  mercury  and  chalk  may  be 


THE  SYPHILODEBMATA  313 

prescribed  in  doses  of  from  ^  to  \  gr.,  three  times  a  day. 
This  quantity  may  be  increased  or  diminished  according 
to  circumstances.  Keyes  highly  recommends  a  mixture  of 
\  gr.  of  the  bichloride  of  mercury  dissolved  in  6  oz.  of 
water,  of  which  a  teaspoonful  may  be  given  hourly  for  the 
first  day,  then  every  two  hours,  and  finally  every  three 
hours,  or  at  longer  intervals,  unless  it  obviously  disagrees. 
Monti  gives  calomel  in  the  following  combination : 

]$ — Hydrarg.  chlor.  mitis gr.  jss 

Ferri  lactatis gr.  v 

Sacchari  albi q.  s. — M. 

Ft.  chart.,  No.  x. 

S. — One  to  four  a  day. 

Kaposi  recommends  the  tannate  of  mercury. 

It  may  be  administered  in  doses  of  from  -£§  to  \  gr. 
The  employment  of  mercury  by  hypodermic  injection  is 
usually  confined  to  those  cases  in  which  the  symptoms  are 
very  urgent.  Jacobi  suggests  for  this  purpose  a  solution  of  1 
to  2  parts  of  corrosive  sublimate  and  2  of  chloride  of  sodium 
in  400  parts  of  water.  From  10  to  15  drops  may  be  injected 
daily.  Corrosive-sublimate  baths  are  of  value  especially 
as  an  aid  to  other  methods  of  treatment.  7  to  30  gr.,  with 
an  equal  amount  of  ammonium  chloride,  are  dissolved 
in  some  hot  water,  and  added  to  a  bath  containing  8 
gal.  of  water.  The  child  should  remain  in  the  bath  five 
to  ten  minutes  and  be  warmly  wrapped  up  when  taken  out. 
The  bath  may  be  repeated  every  second  or  third  day. 

Iodide  of  potassium  alone,  or  in  combination  with  mer- 
cury, is  indicated  in  late  gummatous  and  osseous  lesions. 
It  may  be  given  well  diluted  in  from  1-  to  5-gr.  doses  a  day, 
or  combined  with  mercury. 

1$ — Hydrarg.  bichloridi gr.  j-ij 

1'otassii  iodidi 3ss/ 

Syr.  aurantii  corticis, 

Aquae aa     5ij — M 

S. — Five  to  ten  drops  in  plenty  of  water  three  times  a  day. 

Taylor. 

In  whatever  form,  the  mercury  is  prescribed,  its  effects 
on  the  child  must  be  closely  watched.  Upon  the  first 


314  VEIT  GROWTHS 

intimation  of  anemia,  bowel  trouble  or  general  debility, 
the  drug  should  be  temporarily  discontinued.  Even  if  the 
patient  is  getting  along  favorably  it  is  a  good  rule  to  sus- 
pend treatment  for  some  days  at  the  end  of  every  month. 
The  treatment  should  be  continued  for  some  time  after  all 
symptoms  have  disappeared,  and  the  patient  should  be 
kept  constantly  under  the  eye  of  the  physician  so  that,  at 
the  first  evidence  of  relapse,  treatment  may  be  immediately 
resumed.  Horwitz  urges  that  a  syphilitic  child  should 
undergo  every  year  from  four  to  six  weeks  of  treatment 
until  the  age  of  puberty.  There  is  much  to  be  said  in  favor 
of  this  plan.  Ulcerations  should  be  treated  with  antisep- 
tics and  dusting  powders.  Affections  of  the  mucous  mem- 
branes, like  "snuffles,"  should  be  treated  by  a  2  per  cent, 
boric  acid  douche,  and  localized  lesions  touched  with 
nitrate  of  sflver  or,  better,  mercuric  nitrate,  in  suitable 
strength. 

MYCOSIS  FTTNGOIDES. 

Description. — This  affection,  first  described  by  Alibert, 
in  1814,  is  among  the  rare  diseases  of  the  skin. 

In  its  early  stage  the  disease  is  characterized  by  certain 
ephemeral,,  or  more  permanent,  cutaneous  disturbances, 
that  have  eczematous,  erythematous,  urticaria],  lichenoid 
or  psoriasiform  features;  and  afterward  bright-red  or 
pinkish,  irregularly  shaped  and  distributed  patches  appear. 
These  may  be  small  and  isolated,  or  large  and  confluent. 
These  patches  in  time  become  somewhat  elevated  above 
the  surface,  and  are  the  seat  of  marked  itching  and  burning. 

This  superficial  stage  of  the  disease  may  endure  for 
months  or  years,  but  finally  the  infiltration  increases,  and 
leads  to  the  formation  of  reddened,  thickened  plaques. 
These  lesions  come  and  go  more  or  less  rapidly.  The 
tumors  that  constitute  the  characteristic  feature  of  the 
affection  may  be  developed  from  these  infiltrations,  or  they 
may  appear  on  hitherto  uninvolved  regions  of  the  skin- 
Tbe  tumors  are  of  a  bright  or  dark  red,  sometimes  bluish. 


MYCOSIS  FUXGOIDES  315 

red  color,  and  were  compared  by  Alibert  to  tomatoes. 
They  are  sharply  defined,  ovalish  or  hemispherical,  and 
van-  from  pea  to  orange  size.  Their  epidermal  covering 
is  smooth  and  shiny,  or  the  surface  may  be  excoriated  and 
give  off  a  thin,  serous,  bloody  discharge,  with  the  formation 
of  a  crust.  Suppuration  is  rare.  At  this  time  subjective 
sensations  are  slight.  The  tumors  sometimes  grow  rapidly, 
sometimes  very  slowly,  but  having  attained  a  certain 
dimension,  spontaneous  involution  is  the  rule,  leaving  no 
trace  behind.  The  disease,  however,  is  kept  up  by  the 
continual  reappearance  of  new  lesions. 

Painless  enlargement  of  the  lymphatic  glands  is  present 
in  most  cases.  The  general  health  may  remain  fairly  good 
for  years,  but  finally  the  patient  succumbs  to  increasing 
cachexia,  only  a  few  cases  so  far  reported  having  recovered. 
The  average  duration  of  the  disease  is  from  five  to  eight 
years. 

In  another  type  of  the  disease  the  characteristic  tumors 
may  be  the  first  evidence  of  the  malady.  They  do  not 
disappear  as  in  the  form  just  described,  and  death  ensues 
in  from  a  few  months  to  one  or  two  years. 

The  disease  does  not  appear  to  be  contagious.  Most  of 
the  cases  have  been  in  males  over  thirty  years  old,  although 
the  three  cases  that  we  have  had  under  our  care  were  in 
women.  A  number  of  microorganisms  have  been  observed 
in  the  affected  tissues,  but  none  has  yet  been  shown  to 
have  a  causative  relation  to  the  disease. 

The  tumors  are  made  up  of  round  cells  lying  in  the 
interspaces  of  a  delicate  reticulum.  The  growth  was  form- 
erly regarded  as  a  lymphosarcoma,  but  is  now  thought  to  be 
a  granuloma. 

In  its  erythematous  stage  mycosis  fungoides  may  greatly 
resemble  eczema,  but  the  patches  are  more  defined,  more 
infiltrated,  and  less  weeping  than  in  the  latter  disease. 
After  the  tumors  have  formed  the  disease  may  resemble 
generalized  sarcoma  or  lep: 

Prognosis. — The  prognosis  is  bad.  The  cases  in  which 
the  formation  of  tumors  is  the  first  evidence  of  the  disease 


316  XEW  GROWTHS 

run  a  more  rapid  course  than  those  in  which  there  is  a 
premycotic  stage. 

Treatment. — Up  to  the  present  time  no  internal  treatment 
has  proved  of  much  avail,  although  Koebner  and  Geber 
each  report  the  case  of  a  patient  apparently  cured  by  the 
hypodermic  injection  of  arsenic,  and  Crocker  saw  the  dis- 
ease disappear  after  purgation  in  one  instance.  The  last- 
mentioned  authority  advises  salicin  in  the  pre-ulcerative 
stage,  but  after  ulceration  has  begun  neither  salicin  nor 
other  drugs  seem  to  be  of  any  value.  In  one  of  our  cases 
thyroid  extract  appeared  to  do  good  in  the  beginning,  but 
later  apparently  had  no  influence  on  the  course  of  the 
disease. 

Bazin's  observation  of  a  cure  after  erysipelas  encouraged 
one  of  us  to  use  the  Coley  toxins  in  one  case;  no  good 
effect  was  apparent. 

The  ulcerations  may  be  dressed  with  the  usual  anti- 
septic powders,  such  as  xeroform  or  aristol,  or  these  drugs 
may  be  used  in  salve  form.  The  itching  may  be  greatly 
relieved  by  painting  on  a  paste  of  oxide  of  zinc,  ?  oz.,  with 
2  oz.  each  of  mucilage  of  acacia  and  glycerin,  and  1  or  2 
per  cent,  of  carbolic  acid.  A  lotion  of  menthol  and  carbolic 
acid  (see  urticaria)  is  also  useful. 

One  must  hail  with  delight  the  x-rays  as  a  measure 
which  holds  forth  a  promise  of  relief  in  this  hitherto  in- 
coercible  and  most  horrible  malady.  Scholtz,  in  1902, 
reported  3  cases  treated  by  x-rays.  Small  tumors  dis- 
appeared under  raying  of  necrotizing  intensity.  In  2  of 
these,  however,  new  foci  appeared  at  other  points.  Jamie- 
son,  Hyde,  Marsh,  Stainer,  Elliot,  Carrier,  Dubois- 
Havenith,  Belot,  and  Pusey  have  reported  cures,  and  some 
six  other  observers,  favorable  results.  The  agonizing 
pruritus  was  in  all  cases  relieved  or  lessened.  The  treatment 
is  apparently  beneficial  at  all  stages  of  the  disease.  Belot 
gave  each  tumor  a  large  dose,  allowing  twelve  to  twenty 
days  to  elapse  between  sittings.  According  to  Lustgarten, 
"a  single  twenty-minute  exposure  will  produce  a  dermatitis 
on  any  part  of  the  body,  followed  by  complete  disappear- 


SARCOMA   CUTIS  317 

ance  of  the  lesion."    Others  have  witnessed  good  effects 
without  appreciable  reaction. 

Jackson  and  others  have  noted  recurrence  after  raying. 
Again,  the  results  have  been  apparently  permanent. 


SARCOMA  CUTIS. 

Description. — Owing  to  the  many  clinical  varieties  that 
are  encountered,  it  is  a  matter  of  some  difficulty  to  present 
a  satisfactory  description  of  the  affection. 

In  most  instances  sarcoma  of  the  skin  is  secondary  to  a 
similar  growth  in  some  other  organ.  Not  infrequently, 
however,  the  disease  occurs  primarily  in  the  skin.  Clini- 
cally, sarcomata  of  the  skin  may  be  divided  into  the  pig- 
mented  and  the  non-pigmented  forms. 

Melanotic  Sarcoma. — This  is  the  most  frequent  type  of 
the  disease.  These  growths  may  occur  in  vascular  or  warty 
moles,  or  spring  from  the  apparently  healthy  skin.  Accord- 
ing to  Fordyce  the  uveal  tract  is  the  point  of  origin  of  more 
than  one-half  of  the  pigmented  sarcomata  of  the  skin. 

Starting  from  a  mole,  a  spongy,  black  tumor  develops. 
In  the  course  of  a  few  weeks  or  months,  generally  first 
adjacent  to  the  original  lesion,  numbers  of  small,  firm, 
pigmented  masses  appear.  These  small  tumors  run  into 
larger  masses,  ulceration  occurs,  the  lymphatics  become 
affected,  and,  after  involving  the  skin  more  or  less  generally, 
metastasis  to  internal  organs  occurs.  This  form  of  sarcoma 
is  generally  rapidly  fatal.  Hutchinson  has  described, 
under  the  title  of  melanotic  whitlow,  a  special  type  of 
melanotic  sarcoma  that  begins  as  a  chronic  onychitis  with 
a  slight  pigmentation;  gradually  a  dark,  fungating  tumor 
develops,  and  the  sarcoma  subsequently  becomes  general- 
ized. Unna  thinks  that  all  malignant  new  growths 
originating  from  moles  are  probably  carcinomatous,  but 
this  opinion  has  been  disputed. 

Non-pigmented  Sarcoma. — Non-pigmented  sarcoma 
may  exist  as  a  single  growth,  or  large  numbers  of  tumors  may 


318  NEW  GROWTHS 

be  present.  In  some  cases  the  first  tumor  springs  from  a 
mole  or  scar  which  has  been  irritated.  About  this  other 
tumors  develop  until  a  whole  part  or  extremity  is  thickly 
studded  with  them.  The  individual  growths  vary  from 
pea  to  pigeon's  egg  size  or  larger,  are  smoothly  round  or 
tabulated,  and  usually  firm  to  the  touch.  The  skin  over  the 
lesion  is,  at  least  in  the  earlier  stages,  normal  in  color,  but 
as  the  malady  progresses  it  assumes  a  livid  or  reddish  hue. 
In  the  course  of  time  the  skin  lying  between  the  growths 
becomes  swollen,  red,  and  infiltrated.  A  limb  may  thus 
come  to  resemble  a  member  affected  with  elephantiasis. 
In  a  few  months  the  nodules  coalesce,  break  down,  and 
ulcerate.  The  clinical  history  and  appearance  of  this  form 
of  the  disease  will  vary  much  according  to  the  number  of 
tumors  and  their  anatomical  constitution. 

The  course  is  usually  toward  a  rapidly  fatal  issue. 

Localized  Non-pigmented  Sarcoma. — This  type  of  sar- 
coma may  follow  a  blow  or  develop  from  a  nevus  or  other 
lesion  of  the  skin.  The  growth  rarely  reaches  a  size  larger 
than  an  orange.  The  skin  over  the  tumor  may  be  normal 
in  color  or  of  a  darker  hue.  After  a  variable  time  ulcera- 
tion  occurs,  and  secondary  tumors  form  in  the  skin,  viscera, 
or  lymphatics.  It  should  be  mentioned  that  both  in  leu- 
kemia and  pseudoleukemia,  tumors  and  plaques  of  infiltra- 
tion, probably  sarcomatous  in  their  histology,  may  develop 
in  the  skin  and  other  organs. 

Idiopathic  Multiple  Pigmented  Sarcoma. — This  form 
of  the  disease,  first  described  by  Kaposi,1  is  very  infrequent. 
It  generally  occurs  in  males  and  in  middle  life,  and  mani- 
fests itself  in  the  beginning  in  the  shape  of  reddish-brown, 
or  plum-colored,  pea-sized  tumors,  on  the  flexor  or  extensor 
surfaces  of  the  hands  or  feet.  Similar  tumors  appear  on 
the  legs,  arms,  and  thighs  before  the  trunk  or  face  is  invaded. 
In  a  case  seen  by  one  of  us  telangiectases  ramified  over  the 
infiltrated  plaques  on  the  face.  The  tumors  rarely  ulcerate, 
but  they  often  undergo  involution,  leaving  pigmented  scars. 

1  This  affection  was  Inter  called,  by  Kaposi,  Sarcoma  Idiopathicum 
Multiplex  Ha-morrhagicum. 


SARCOMA  CUT  IS  319 

When,  in  the  course  of  two  or  three  years,  the  lesions  appear 
on  the  trunk  and  face,  the  fatal  termination  is  near.  The 
tumors  may  form  upon  the  mucous  membranes.  Sooner 
or  later  dysenteric  symptoms,  fever,  marasmus,  etc.,  set  in 
and  the  patient  succumbs.  All  cases,  it  must  be  noted, 
do  not  end  in  death.  One  of  us  reported  an  example  of 
this  disease  in  which  the  growths  underwent  spontaneous 
involution  and  the  patient  remained  well  after  sixteen 
years.1  Brayton  records  a  case  in  which  the  disease  had 
existed  for  twenty-five  years,  some  of  the  lesions  disappear- 
ing, from  time  to  time,  while  new  ones  developed.2  In 
arriving  at  a  diagnosis  it  is  important  to  differentiate  the 
large  papular  and  the  gummatous  syphilide,  mycosis  fun- 
goides,  leprosy  and,  perhaps,  lupus. 

Treatment. — The  treatment  of  melanotic  sarcoma  after 
dissemination  is  futile.  There  may  be  some  chance  of 
cure  if  the  preliminary  growth  is  removed  at  an  early  date. 
Moles  and  warty  growths,  especially  on  the  face,  should  be 
removed  as  a  precautionary  measure  under  any  circum- 
stances, and  all  the  more  so  if  a  pigmented  mole,  for 
example,  should  show  signs  of  beginning  irritation. 

Fordyce  advises  arsenic  by  the  mouth  or  hypodermically 
for  non-pigmented  sarcoma.  We,  personally,  have  seen  no 
good  results  from  its  use.  Koebner,  Lustgarten,  Hyde,  and 
others  have  reported  cures  of  idiopathic  multiple  sarcoma 
following  the  administration  of  arsenic  hypodermically. 
We  think  this  treatment  should  always  be  tried;  but  of 
2  patients  treated  by  one  of  us,3  1,  to  whom  arsenic  was 
faithfully  administered,  died,  while  the  other,  who  received 
absolutely  no  treatment  at  all,  recovered. 

Coley's  treatment  by  the  mixed  toxins  of  erysipelas  and 
the  Bacillus  prodigiosus  has  yielded  some  astonishing 
results  in  the  spindle-celled  variety,  but  is  less  efficient  in 
other  forms.  One  of  us  witnessed  a  cure  in  a  rapidly 

1  Harclaway.    Journal  of  Cutaneous  Diseases,  p.  1,  1883,  and  p.  21 , 
1890.    This  man  is  still  living  and  in  good  health  (1907). 

2  Indiana  Medical  Journal.  November,  1893. 

3  Hardaway. 


320  NEW  GROWTHS 

growing  lesion,  without  recurrence,  the  patient  dying  eight 
years  later  of  another  malady.  The  reactions  are  sharp 
and  severe,  but  without  ulterior  bad  effects.  In  our  opin- 
ion the  method  should  always  be  given  a  thorough  trial.  It 
should  be  distinctly  understood  that  erysipelas  cannot  be 
conveyed  by  this  method,  as  the  living  streptococci  are  not 
employed.  This  agent  is  more  fully  considered  in  Part  II. 

The  trypsin  treatment  (see  Part  II)  may  be  given  a  trial 
when  the  mixed  toxins  fail. 

Reports  on  the  efficacy  of  the  x-rays  in  this  neoplasm  are 
somewhat  conflicting.  While  most  authorities,  writh  whom 
our  experience  leads  us  to  agree,  believe  sarcoma  to  be  less 
amenable  to  irradiation  than  carcinoma  (thus  Codman 
collects  35  cases,  of  which  15  were  improved  and  20 
unimproved),  a  few,  among  whom  Holzknecht,  express  a 
contrary  opinion.  Morton  holds  that  the  two  respond 
similarly  to  treatment.  This  divergence  is  largely  refer- 
able to  the  fact  that  sarcomata  differ  widely  in  structure. 
Kienbock  finds  that  "round-celled  sarcomata  and  endo- 
theliomata  of  the  face,  originating  in  the  oral  or  buccal 
cavities,  are  particularly  influenced  by  radiotherapy." 
Radium  was  successfully  employed  in  melanosarcoma  in 
the  late  Professor  Gussenbauer's  Vienna  clinic. 

Sarcoma  presenting  such  a  variety  in  kind,  size,  and  loca- 
tion, it  is  evident  that  no  general  rules  for  treatment  can 
be  laid  down,  except  that  they  should  be  surgically  removed 
whenever  practicable,  after  which  the  rays  may  be  employed 
to  diminish  the  chances  of  recurrence,  without  awaiting 
cicatrization.  Allen  states  that  recurrence  is  the  rule. 


LEPROSY. 

Description. — Lepra  or  leprosy  is  a  chronic,  endemic, 
specific  disease  characterized  by  various  alterations  in  the 
tissues  and  organs  of  the  body,  and  usually  ending  in  death. 
Although  all  forms  of  the  disease  are  due  to  the  same  cause, 
it  is  convenient  on  clinical  grounds  to  divide  leprosy  into 


LEPROSY  321 

(1)  the  tubercular  or  nodular,  (2)  the  anesthetic  or  ner- 
vous, and  (3)  the  mixed  types. 

Nodular  Leprosy. — After  a  variable  period  of  general 
malaise,  dyspepsia,  constipation  or  diarrhea,  vertigo, 
profuse  perspiration  or  local  anidrosis,  general  infection  of 
the  system  is  declared  by  a  chill  and  a  rise  of  temperature 
to  103°  or  104°  F.  These  symptoms  may  last  days,  weeks, 
or  months  before  the  leprous  exanthem  makes  its  appear- 
ance. The  eruption  is  usually  situated  on  the  face,  ears, 
trunk,  and  extremities,  and  consists  of  erythematous, 
hyperesthetic,  sharply  limited  macules  of  a  reddish-brown 
color,  and  varying  in  size  from  a  bean  or  less  to  several 
inches  in  diameter. 

The  first  crop  of  eruption  may  fade  away,  to  be  followed, 
with  renewed  febrile  exacerbation,  by  others,  or  the  lesions 
may  change  to  a  permanent  brownish-red  stain ;  and  these 
various  processes  may  continue  for  months  without  further 
alterations.  The  spots  are  often  hyperesthetic  at  first,  and 
later  may  become  anesthetic.  This  latter  condition  may 
be  detected  in  apparently  normal  regions  of  integument. 

Finally,  however,  tubercles  in  the  shape  of  pale,  red, 
very  small  elevations,  which  enlarge  to  the  size  of  a  pea  or 
filbert,  of  a  brownish  color,  make  their  appearance.  These 
may  occur  anywhere,  but  the  face,  penis,  scrotum,  breasts, 
and  limbs  are  the  most  usual  sites  of  development.  The 
individual  lesions  may  attain  great  size,  or  by  coalescence 
may  form  larger,  irregular,  nodulated  masses.  On  the 
other  hand,  the  original  erythematous  patches  may  become 
profoundly  infiltrated,  brownish  elevations. 

The  leprous  deposit  also  occurs  on  any  of  the  mucous 
membranes,  and  produces  quite  characteristic  symptoms 
when  the  cavity  of  the  nose  and  the  larynx  are  involved. 
In  most  cases,  owing  to  the  excessive  deposit  of  leprous 
nodules  and  thickenings  on  the  face,  the  countenance 
assumes  the  well-marked  leonine  expression,  giving  an 
aspect  of  brutality  to  the  unfortunate  sufferer  that  is  repul- 
sive in  the  extreme.  As  a  result  of  various  circumstances, 
the  course  of  the  tubercles  may  present  very  different  ter- 
21 


322  NEW  GROWTHS 

minations.  Sometimes  the  lesions  undergo  involution, 
leaving  brown  macules  in  their  wake,  or  atrophic  scars, 
or,  what  is  very  usual,  ulceration  may  take  place,  the  ulcers 
being  superficial,  indolent,  and  healing  only  after  a  long 
time,  often  only  to  break  down  again.  The  lymphatic 
glands  become  enormously  enlarged.  From  time  to  time 
acute  exacerbations  occur,  new  tubercles  appearing  after 
each  attack,  but  usually  with  diminishing  frequency  as  the 
disorder  advances,  to  cease  altogether  after  five  or  six 
years  (Hillis).  After  months  or  years,  with  progressive 
emaciation,  the  patient  will  succumb,  either  directly  from 
extensive  ulcerations,  from  interference  with  the  respira- 
tory function,  to  some  intercurrent  affection,  or  from  dis- 
orders of  internal  organs  due  to  invasion  of  the  lepra 
bacillus.  The  features  of  the  anesthetic  or  nervous  form 
of  the  disease  may,  at  any  time,  be  superadded,  thus  pro- 
ducing what  is  called  the  "mixed  variety."  Nodular 
leprosy  lasts,  on  an  average,  about  nine  years. 

Anesthetic  Leprosy. — Febrile  symptoms  are  absent  in 
nerve  leprosy  as  a  rule,  but  the  patient  complains  much  of 
uncomfortable  feelings  of  chilliness,  and  suffers  more  or 
less  from  ill-defined  gastric  and  other  disturbances.  Lan- 
cinating pains  are  felt  in  various  parts,  together  with 
sensations  of  numbness  or  burning.  Muscular  weakness 
is  an  early  symptom.  Numerous  small  blebs  make  their 
appearance  on  the  extremities,  which  later  in  the  disease 
assume  considerable  proportions.  After  a  time  erythe- 
matous  spots  and  patches  come  out  on  the  trunk,  limbs, 
and  face.  They  have  a  certain  resemblance  to  the  lesions 
of  erythema  multiforme,  but  are  larger  and  more  irregular. 
The  macules  are  one  or  two  inches  in  diameter,  and  later 
by  coalescence  may  cover  large  areas,  the  first  spots  dis- 
appearing and  reappearing,  and  new  lesions  developing 
from  time  to  time.  It  is  said  that  the  patches  are  rarely 
insensitive  at  this  time,  but  that  the  secretion  of  sweat  is 
absent.  Anesthesia  is  often  apparent  in  places  where  no 
noted  changes  have  occurred  in  the  skin,  especially  regions 
supplied  with  cutaneous  nerves  from  the  ulnar  and  pero- 


LEPROSY  323 

neal.  In  the  spreading  state  of  the  malady  the  spots  enlarge 
peripherally,  the  borders  are  raised,  studded  with  papules 
or  vesicles,  and  the  centres  become  hairless,  wrinkled,  dry, 
atrophic,  and  covered  with  white,  furfuraceous  scales.  In 
addition  to  the  well-marked  anesthesia  that  is  now  present, 
large  bullae  form,  mostly  on  the  extremities.  Owing  to  the 
presence  of  leprous  deposits  in  the  nerves,  these  latter, 
especially  the  ulnar,  become  enlarged,  and  can  be  plainly 
felt  under  the  skin.  Muscular  atrophy  is  a  prominent 
symptom,  the  wasting  being  first  visible  in  the  thenar  and 
hypothenar  eminences,  and  involving  the  muscles  of  the 
hand,  forearm,  and  even  the  upper  arm. 

Motor  paralysis,  especially  of  the  facial  nerve,  may  be 
combined  with  the  sensory,  and  after  awrhile  the  mimic 
muscles  of  the  face  are  implicated.  Finally,  after  the 
various  local  processes  have  been  long  established — e.  g., 
anesthesia,  analgesia,  and  atrophy — the  osseous  system 
becomes  involved,  and  there  arises  the  combination  of 
symptoms  called  lepra  mutilans. 

Sometimes  the  deep  ulcers  left  by  the  bullse  extend  and 
cause  profound  destruction  of  the  connective  tissue,  muscles 
and  fascia?,  and  in  certain  situations,  such  as  the  ankles, 
wrists,  and  feet,  bones  are  laid  bare  and  caries  appears. 
As  the  wounds  are  not  painful,  they  are  often  neglected, 
and  large  parts  of  the  bone  may  be  destroyed,  the  articular 
cavities  are  opened,  and  spontaneous  amputations  occur. 
In  other  instances,  after  the  anesthesia  has  become  pro- 
nounced, swellings  will  appear  around  the  phalanges  and 
the  metacarpal  and  metatarsal  bones,  which  will  finally 
turn  livid,  fluctuate  and  burst,  and  the  denuded  bones 
may  be  seen  or  felt,  and  finally  be  cast  off. 

Gradually,  as  the  case  advances,  the  symptoms  of 
general  marasmus  supervene,  and  the  patient  dies  from 
exhaustion  or  else  is  carried  off  by  some  intercurrent  dis- 
ease. In  a  few  instances  the  disease  may  be  arrested  after 
having  progressed  to  a  certain  extent,  or  even  after  marked 
changes  have  taken  place.  After  a  time  anesthetic  leprosy 
may  become  complicated  with  the  tuberose  variety.  The 


324  NEW  GROWTHS 

duration  of  the  anesthetic  or  nervous  form  of  leprosy  may 
be  from  eighteen  to  nineteen  years. 

Mixed  Leprosy. — As  already  stated,  in  some  cases  the 
features  of  tuberculated  and  anesthetic  leprosy  may  be 
conjoined.  This  state  may  begin  with  one  form  or  the 
other  of  the  two  chief  types  of  the  disease,  or  it  may  present 
both  forms  from  the  beginning,  in  which  case  its  progress 
is  more  rapid.  It  is  now  conceded  that  the  direct  exciting 
cause  of  leprosy  is  the  bacillus  discovered  by  A.  Hansen, 
in  1874. 

No  initial  lesion  has  ever  been  detected  in  leprosy,  and 
the  method  of  the  introduction  of  the  disease  into  the  body 
is  unknown.  It  is  presumed  that  the  exhalations  from  the 
nose  and  mouth  may  be,  in  some  instances,  responsible 
for  contagion,  and  that  the  bacillus  may  also  gain  an 
entrance  through  abrasions  of  the  skin  and  through  in- 
gestion  of  food. 

A  few  words  in  regard  to  the  diagnosis  of  leprosy  may 
not  be  out  of  place  in  this  connection. 

In  countries  where  leprosy  prevails  as  an  epidemic  the 
prodromic  symptoms  are  always  likely  to  arouse  suspicion, 
but  where  the  disease  is  occasional,  they  are  apt  to  be  con- 
founded with  malaria  or  rheumatism  until  the  appearance 
of  the  more  distinctive  features  of  the  disease,  such  as 
anesthesia  and  leprous  macules,  puts  the  diagnosis  at  rest. 
It  is  quite  possible  to  mistake  macular  leprosy  for  exudative 
erythema  and  the  erythematous  syphilide,  but  in  neither  of 
these  conditions  is  there  any  alteration  of  cutaneous  s< 'Mo- 
bility— that  is,  hyperesthesia  or  anesthesia — and  the 
appearance  of  the  lesions  is  different;  besides,  as  regards 
syphilis,  there  would  at  this  time  be  other  symptoms 
present. 

Tubercular  syphilis  and  nodular  leprosy  bear  a  close 
resemblance  if  considered  superficially,  but  the  tubercles 
of  lepra  have  especial  sites  where  those  of  syphilis  are 
rarely  found;  their  course  is  slower,  and  anesthesia  may 
be  present.  The  nodules  of  lupus  have  a  more  chronic 
history,  a  dissimilar  course,  and  a  different  arrangement. 


LEPROSY  325 

In  ulcerative  lesions  of  the  palate  and  nose  the  history  of 
the  case  and  the  concomitant  symptoms  must  receive  due 
weight  in  reaching  a  conclusion. 

Leprosy  should  also  be  differentiated  from  syringo- 
myelia,  leucoderma,  morphea,  pemphigus,  and  progressive 
muscular  atrophy.  Examination  for  the  lepra  bacillus 
should  always  be  made. 

Treatment.1— Until  recent  years  the  treatment  of  leprosy 
was  based  purely  upon  sanitary  methods  directed  chiefly 
at  the  protection  of  the  public  at  the  expense  of  the  victim 
of  the  disease.  The  popular  conception  of  the  affliction, 
implanted  by  the  vague  but  graphic  descriptions  contained 
in  the  Bible,  were  shared  in  large  part  by  the  medical  pro- 
fession. Here  and  there  some  essays  at  treatment  were 
early  recorded,  but  with  lack  of  exactness  in  procedure, 
so  as  to  practically  render  them  of  little  value.  Still,  most 
intelligent  governments  segregate  those  affected  with 
leprosy  in  asylums,  hospitals,  and  colonies  which  are  con- 
ducted with  varying  degrees  of  care,  medical  and  other- 
wise. The  humanitarian  episode  of  Father  Damien's 
career  occasioned  a  wholesale  investigation  of  the  disease 
on  the  part  of  the  British  government  in  the  later  '80 's, 
resulting  in  an  exhaustive  report  which  largely  educated 
those  interested  in  the  methods  of  the  spread  of  the  disease 
and  in  the  modes  of  treatment  then  in  vogue.  The  Con- 
ference of  Berlin,  in  1897,  further  exploited  the  pathology, 
symptomatology,  and  therapy  of  this  disease. 

With  the  discovery  of  the  bacillus  of  leprosy,  a  tangible 
point  of  attack  was  determined,  and  various  theories  have 
been  born  and  spread  directed  at  serum  treatment. 

It  is  absolutely  conceded  that  the  segregation  of  lepers 
in  wholesome  colonies  does  succeed  in  reducing  the  numeri- 
cal importance  of  the  disease  as  well  as  the  danger  of  spread 
among  susceptible  people.  Neither  climate,  diet  nor 
environment  seem  to  be  primary  factors  so  far  as  the  dis- 
rase  is  concerned;  the  consensus  of  opinion  points  to  a 

1  By  Isadore  Dyer,  Ph.D.,  M.D.,  of  New  Orleans. 


326  NEW  GROWTHS 

direct  acquisition  of  the  bacilli  through  the  respiratory 
tract  by  way  of  the  nose  and  mouth.  The  advantages 
obtained  in  systematic  treatment,  hygienic  care  and  diet, 
which  can  be  imposed  in  an  asylum  for  lepers,  point  to 
segregation  in  such  an  institution  as  the  best  means  of 
accomplishing  results  in  a  therapeutic  way.  The  case 
which  is  individualized  usually  fails  in  systematic  care  and 
is  apt  to  run  the  course  natural  to  a  virulent  disease,  aggres- 
sive in  type  and  progressive  in  its  destructive  tendencies. 

Particular  treatment  of  leprosy  must  depend  upon  the 
individual  patient,  not  necessarily  upon  the  type  of  the 
disease.  The  basis  of  treatment  seems  to  depend  upon  the 
law  of  resistance  in  the  individual.  Like  tuberculosis  and 
syphilis,  leprosy  tends  to  be  self-limited;  in  some  cases 
running  a  natural  course  of  expression  of  the  disease, 
undergoing  gradual  elimination,  until  the  victim  survives 
the  disease,  either  with  no  evidence  of  its  presence,  or  with 
various  degrees  of  those  sequelae  which  are  common  to 
explosive  types.  This  may  go  on  to  actual  mutilation,  stop 
with  this,  and  never  again  show  active  evidences  in  the  leper. 

As  with  the  two  diseases  referred  to,  leprosy  more  often 
finds  focuses  for  the  deposit  of  its  bacilli,  and  these  colonize 
to  the  extent  of  provoking  systemic  disturbances,  nerve 
disorders,  and  disfigurement  of  the  cutaneous  surfaces. 
So  long  as  fresh  colonies  of  the  bacilli  find  proper  nutrition 
they  go  on  developing;  but  if  a  resistance  can  be  estab- 
lished, the  areas  of  the  disease  become  circumscribed,  the 
bacilli  are  starved,  resolution  occurs,  and  the  patient  may 
get  well,  as  happens  in  the  cases  reported  from  the  various 
centres  infected  with  this  disease. 

The  treatment  of  leprosy  is  based  upon  the  personal 
hygiene  of  the  patient,  the  introduction  into  the  economy 
of  sera,  or  drugs,  and  the  immediate  application  to  the 
manifestations  of  the  disease  of  destructive  agents,  ab- 
sorbents, or  other  treatment  directed  at  producing  their 
resolution. 

The  sera  so  far  advanced  have  one  and  another  failed  in 
their  uniform  application  to  the  disease.  Among  these 


LEPROSY  327 

may  be  mentioned  prominently  that  of  Carasquilla,  of 
Bogota,  United  States  of  Colombia,  and  the  "leprolin" 
of  Rost,  of  Rangoon,  India.  Both  of  these  are  derived 
from  the  fresh  tubercle  of  leprosy,  the  first  through  attenu- 
ating the  bacillus;  the  second,  consisting  in  the  employ- 
ment of  by-products  derived  from  cultures  in  various  media. 
Carasquilla,  himself,  obtained  results  which  were  note- 
worthy, but  no  one  else  succeeded  as  he  did,  either  with 
serum  made  by  him,  or  by  his  method.  Rost  reported  a 
large  number  of  cases  treated,  in  a  good  percentage  of  which 
rapid  results  were  obtained,  but,  later,  he  himself  found 
that  these  results  were  not  permanent. 

The  experience  of  the  writer  of  this  article  with  snake 
venom  is  a  matter  of  record.  Influenced  by  the  popular 
superstitions  with  regard  to  the  influence  of  snake  venom 
derived  from  the  actual  bite  of  the  reptile,  and  also  by  the 
experience  of  Carreau  with  a  leper  bitten  by  a  viper  in 
Jamaica,  experiments  were  conducted  in  a  series  of  cases 
injected  with  the  antivenomous  serum  of  Calmette  obtained 
from  the  Pasteur  Institute  at  Lisle,  France.  The  results 
are  related  in  detail  in  the  report  made  to  the  Berlin  Con- 
ference1 and  in  a  more  recent  paper.2 

Among  the  drugs  used  in  the  treatment  of  leprosy  may 
be  mentioned  ichthyol,  salicylate  of  soda,  arsenic,  strych- 
nine, hoang-nan,  mercurial  salts,  chaulmoogra  oil,  gurjun 
oil,  red  mangrove,  tua-tua,  chlorate  of  potash,  europhen, 
and  iodine  salts.  Of  these  the  chaulmoogra  oil  has  been 
most  extensively  used  and  over  a  longer  period  of  time. 
The  properties  of  chaulmoogra  oil  (gynocardia  odorata)  have 
been  known  to  the  natives  of  India  for  a  great  many  years. 

The  extensive  demand  for  the  oil  has  occasioned  numer- 
ous substitutes,  none  of  which  seem  to  have  the  same 
virtues.  Bibb,  in  his  paper  on  the  treatment  of  leprosy 
(Alvarenga  Prize  Essay,  1895)  is  emphatic  in  his  expres- 
sion of  belief  that  this  remedy  is  a  specific  for  the  disease. 
Our  own  experience  would  confirm  a  belief  in  its  prime 

1  New  Orleans  Medical  and  Surgical  Journal,  October,  1897. 

2  The  Cure  of  Leprosy,  Medical  News,  July  29,  1905. 


328  NEW  GROWTHS 

usefulness.  Hutchinson  has  reported  cases  cured  with 
arsenic;  likewise  Fox.  Crocker  has  effected  permanent 
results  with  hypodermic  injections  with  the  perchloride 
of  mercury ;  Goldschmidt  has  obtained  cures  with  europhen 
in  oil,  and  various  reports  have  been  made  of  the  excellent 
results  observed  after  the  administration  of  salicylate  of 
soda. 

After  observation  of  the  disease  during  nearly  fifteen 
years,  and  with  the  successful  treatment  of  20  cases,  12 
of  which  have  been  permanently  cured,  the  author  has 
arrived  at  the  following  observations  with  regard  to  this 
disease : 

1.  Full  diet,  restricting  only  indigestible  foods,  is  indi- 
cated.   The  disease  seems  nowise  to  be  affected  by  fish  or 
any  other  particular  article  of  diet. 

2.  Baths  are  essential  in  the  treatment.     Hot  baths 
twice  a  day,  with  or  without  carbonate  of  soda,  are  effective. 

3.  The  patient  needs  tonics,  febrifuges,  and  should  be 
watched  for  intercurrent  or  complicating  diseases,  such 
as  malarial  infection,  pleurisy,  pneumonia,  la  grippe,  and 
the  like. 

4.  Strychnine  is  a  sine  qua  non  in  the  treatment  of  leprosy. 
My  assistants  and  I  lay  down  the  rule  that  a  leper  should 
always  take  strychnine — the  sort  and  size  of  dose  to  be 
regulated  by  the  patient  himself. 

5.  When  chaulmoogra  oil  is  given,  it  is  better  endured 
before  meals  than  after.     It  is  best  taken  in  capsules,  in 
hot  milk,  or  in  milk  of  magnesia.    The  dosage  should  be 
begun  with  a  small  amount,  say  3  drops,  and  increased 
every  second  or  third  day  until  as  much  as  120  to  150  drops 
of  the  oil  are  taken  at  the  dose. 

At  times  it  is  advisable  to  give  the  oil  in  pill  form.  This 
can  be  done  either  by  combining  it  with  the  extract  of  nux 
vomica  and  ordinary  excipients,  or  a  very  effective  way  is 
with  tragacanth  and  common  soap. 

6.  Above  all  things  individualize  the  patient.     Watch 
for  improvement,  and  if  it  does  not  show  in  three  months, 
wait  six  months;  if  it  does  not  show  in  six  months,  wait  a 


LEPROSY  329 

year,  or  longer.  But  keep  on  driving  at  the  treatment  until 
the  patient  dies  or  gets  well. 

7.  When  all  evidences  of  the  disease  are  gone,  insist  on 
a  continuance  of  treatment.  It  may  not  be  necessary,  but 
it  makes  sure. 

Regarding  the  local  treatment  of  leprosy,  this  must 
necessarily  be  considered  as  subsidiary  to  internal  medi- 
cation. There  is  undoubted  benefit  to  be  derived  from 
frequent  friction  with  chaulmoogra  oil,  olive  oil,  castor 
oil,  etc.,  with  energetic  rubbing  of  the  skin.  There  is 
evidently  some  aid  in  resolution  of  patent  lesions,  and 
undoubtedly  a  certain  amount  of  absorption  of  the  fatty 
substance  itself.  The  iodide  of  lead  ointment,  used  in  the 
same  way,  is  of  marked  value  in  certain  cases. 

With  tubercles  on  the  face,  hands,  or  where  these  are 
discrete,  the  use  of  the  Paquelin  cautery  is  indicated  for  the 
further  destruction  of  such  lesions.  The  electric  needle 
deeply  introduced,  and  carbolic  acid  or  iodine,  freely 
injected  in  these  growths,  cause  their  resolution.  The 
same  object  is  attained  by  the  Japanese  through  the  use 
of  "moxa,"  which  are  really  the  same  as  "punk,"  or  closely 
packed  waste,  arranged  like  a  wick  and  having  a  gummy 
substance  at  one  end  by  means  of  which  it  may  be  applied 
to  the  area  to  be  destroyed.  These  devices  are  ignited  and 
burned  to  their  base,  incidentally  destroying  the  lesion 
underneath.  Bichloride  of  mercury  in  collodion,  arsenical 
paste,  the  chloride  of  zinc,  and  strong  nitric  or  hydrochloric 
acid  are  likewise  used  in  loco. 

Quite  recently,  Gilchrist,  of  the  United  States  army,  has 
used  radiotherapy  for  the  purpose  of  provoking  the  resolu- 
tion of  leprous  tubercles,  and  has  obtained  favorable  results. 
Reports  have  been  made  from  Manila  on  the  use  of  the 
o>rays,  used  in  a  diffuse  way  for  the  cure  of  the  disease 
generally,  cases  being  instanced  in  which  manifestations 
of  the  disease  have  disappeared  under  the  energetic  employ- 
ment of  the  or-rays.  The  theory  of  the  action  of  this  form 
of  light  treatment  is  unique.  It  argues  that  the  destruction 
of  the  local  manifestations  of  the  disease  results  in  the 


330  NEW  GROWTHS 

absorption  of  the  products  of  such  destruction  in  the  shape 
of  dead  bacilli  and  their  media,  which  are  carried  into  the 
active  circulation  and  act  as  an  engaging  host  against 
active  bacilli  in  the  internal  organs  and  in  remoter  areas 
not  directly  open  to  the  effect  of  the  rays.  The  experi- 
ments are  too  few  to  be  startling  and  need  further  con- 
firmation to  warrant  the  adoption  of  the  method  and  the 
theory.1 

In  conclusion,  be  it  said,  that  the  enlightenment  of  the 
intellectual  division  of  the  medical  profession  with  regard 
to  this  particular  disease  has  grown  remarkably  in  the 
past  thirty  years,  and  the  disease  is  no  longer  considered 
incurable.  More  than  this,  the  laboratory  has  elucidated 
the  exact  method  of  invasion  of  the  tissues  and  has  pointed 
to  the  means  of  relief.  It  remains  earnestly  to  devise 
exact  methods  of  treatment  to  the  end  that  this  disease 
may  be  eradicated,  or  at  any  rate  be  removed  from  among 
the  dangers  to  humanity. 


COLLOID  DEGENERATION  OF  THE  SKIN. 

Description. — This  affection  is  characterized  by  small, 
shining,  lemon-yellow  papules  that  have  the  appearance  of 
vesicles;  but  when  pricked  they  exude  no  fluid,  but  a 
yellowish  jelly.  The  disease  seems  to  be  limited  to  the 
upper  part  of  the  face,  especially  the  forehead,  malar 
regions,  and  the  bridge  of  the  nose.  It  should  not  be  con- 
founded with  papular  xanthoma,  for  in  this  latter  disorder 
the  lesions  are  not  translucent  in  appearance,  and  the  color 
is  more  subdued. 

Treatment. — The  treatment  of  colloid  degeneration  is  to 
enucleate  the  deposit  with  a  dermal  curette,  or  to  effect 
destruction  by  electrolysis. 

1  Grou,  Sequeira,  Crocker,  and  Oudin  have  observed  improvement 
of  irradiated  lesions.  Electricity  has  been  applied  to  anesthetic 
patches.  Beavan  Rake  has  reported  good  results  from  nerve  stretch- 
ing.—W.  A.  H.,  J.  G. 


ADENOMA  SEBACEUM  331 


ADENOMA  SEBACEUM. 

Description. — This  disorder  is  characterized  by  small 
growths  having  their  origin  in  hyperplasia  of  the  sebaceous 
glands.  The  lesions  occur  on  the  face,  most  abundantly 
at  the  sides  of  the  nose,  but  they  are  also  to  be  noted  on  the 
forehead  and  other  parts  of  the  face.  As  a  rule,  they  are 
distributed  symmetrically,  but  exceptionally  they  may  be 
unilateral.  The  little  tumors  are  firm  to  the  touch,  smooth 
or  rough,  whitish  or  yellowish,  or  of  a  bright-crimson  hue 
from  the  development  of  telangiectases.  The  tumors  pre- 
sent no  apertures,  but  a  little  inspissated  sebum  may  be 
pressed  out  after  pricking.  The  growths  are  apparently 
congenital  in  some  cases,  or  occur  early  in  infancy,  but 
an  increase  in  their  size  and  number  is  to  be  noted  at 
puberty.  No  subjective  symptoms  are  present.  For  the 
most  part  the  tumors  undergo  no  change,  but  spontaneous 
involution  occurs  sometimes  in  some  of  them.  Fibromata, 
warts,  nevi,  and  anomalies  of  pigmentation  are  often  seen 
in  connection  with  the  affection.  In  many  instances,  the 
patients  are  epileptics  or  are  otherwise  mentally  defective. 
An  exacj  diagnosis  is  exceedingly  difficult  without  a 
microscopic  examination,  but  it  is  well  to  bear  in  mind 
the  possibility  of  confounding  adenoma  sebaceum  with 
colloid  milium,  multiple  benign  cystic  epithelioma,  acne 
rosacea,  and  the  nodules  of  lupus  vulgaris. 

Treatment. — The  treatment  is  by  excision,  curetting,  the 
cautery,  or  preferably  by  electrolysis.  Jamieson  reported 
an  apparent  cure  by  the  application  of  the  following  paste : 

1$ — Resorcini gr.  xx 

Zinci  oxidi gr.  xl 

Kaolini gr.  ij 

Adipis  benzoati gr.  xxviij — M. 

In  a  recent  case  the  same  author  employed  the  arrays 
without  result.  Harrison  and  Wills  benefited  a  case  by 
phototherapy. 


332  NEW  GROWTHS 


MULTIPLE  BENIGN  CYSTIC  EPITHELIOMA. 

Description. — The  disorder  has  been  described  under  a 
great  variety  of  names,  viz.,  hydradenomes  eVuptifs, 
syringo-cystadenoma,  epithelioma  adenoides  cysticum,  etc. 

According  to  Fordyce,  the  malady  affects  the  face,  chest, 
back,  and  upper  extremities,  and  is  characterized  by  small, 
pale-yellow,  pearly  or  pinkish-colored  tumors  varying  in 
size  from  a  pin's  head  to  a  pea.  The  little  growths  are 
embedded  in  the  skin  and  project  above  the  surface.  They 
are  firm  to  the  touch  and  painless,  the  larger  tumors  being 
tense,  shiny,  freely  movable,  and  occasionally  exhibiting 
a  central  depression.  Some  of  them  are  translucent  and 
look  like  vesicles;  others  are  made  up  of  milium-like 
bodies  and  are  traversed  by  small  vessels.  The  disease 
makes  its  appearance  at  or  before  puberty.  In  one  of  our 
cases  the  disease  first  appeared  at  the  fourteenth  year. 
The  tumors  enlarge  until  they  reach  the  size  of  a  pea, 
rarely  greater,  never  undergo  involution,  and  only  excep- 
tionally ulceration.  They  show  little  tendency  to  malig- 
nancy. The  tumors  bear  no  relation  to  the  sweat  glands, 
but  represent,  histologically,  an  epithelioma  of  .the  skin, 
accompanied  by  colloid  degeneration  and  the  formation 
of  small  cysts  (Bowen). 

The  lesions  may  be  treated  by  the  cautery,  curette,  or 
incision  with  expression  of  the  contents.  Electrolysis  has 
answered  better  in  our  hands. 

Pusey  caused  the  disappearance  of  a  number  of  growths 
in  one  case  by  the  x-rays. 

LEUCOKERATOSIS  BUCCALIS. 

Description. — This  affection,  also  known  as  leucoplakia, 
psoriasis  linguae,  ichthyosis  linguae,  and  smokers'  patches, 
was  first  described  by  Bazin  in  1S08,  and  later  more  espe- 
cially by  Debove,  Schwimmer,  and  others.  Although 
Schwimmer  is  of  opinion  that  the  disease  makes  its  first 


LEUCOKERATOSIS  BUCCALIS  333 

appearance  in  the  form  of  dark-red  spots,  this  is  not  the 
common  experience,  but,  on  the  contrary,  the  lesions  seem 
to  be  from  the  beginning  of  a  pearly  or  slate-gray  color. 
The  lesions  vary  in  size  from  a  small  point  to  areas  cover- 
ing extensive  regions  of  the  affected  parts.  Any  part  of  the 
oral  mucous  membrane  may  be  attacked,  even  the  gums, 
but  a  common  site  is  the  tongue  and  that  portion  of  the 
cheek  on  a  line  with  the  teeth  when  the  latter  are  closed. 
The  patches  in  the  beginning  are  usually  well  defined, 
irregular  in  outline,  barely  elevated,  and  somewhat  dry 
and  rough;  but  the  epithelium  may  be  peeled  off,  dis- 
playing a  smooth,  red  surface  that  is  apt  to  bleed.  At  an 
advanced  stage  of  the  disease,  cracks  may  develop  and  the 
parts  become  stiff  and  dry.  Hypertrophy  of  the  papillae  of 
the  tongue  may  occur  and  may  take  on  a  nodular  appear- 
ance. 

Sometimes  the  patches  may  pass  unobserved  and  the 
disease  remain  quiescent,  and  even  in  rare  instances  entirely 
disappear.  On  the  other  hand,  the  condition  of  leucokera- 
tosis  may  be  general  from  the  beginning.  Again,  it  may 
rapidly  spread  by  extension  of  single  lesions  or  by  the  con- 
fluence of  several.  Epitheliomatous  degeneration  is  always 
to  be  feared  in  these  cases,  appearing  as  a  development  out 
of  a  warty  outgrowth,  from  a  submucous  nodule,  or  in  the 
shape  of  an  ulcer  with  indurated  borders.  Leloir  thinks  that 
the  epitheliomatous  change  is  due  indirectly  to  chronic  irri- 
tation and  is  not  an  essential  development  from  the  hyper- 
keratotic  condition.  This  disorder  occurs  mainly  in  the 
middle  period  of  life  and  in  the  male  sex.  Syphilis  and 
tobacco-smoking  are  the  usually  assigned  causes  of  the 
malady,  but  it  is  known  that  it  may  occur  independently 
of  either  of  these  conditions.  Among  exciting,  or  at  least 
complicating,  factors  may  be  mentioned  spiced  foods, 
strong  drinks,  the  irritation  of  ill-fitting  dental  plates,  etc. 

Treatment. — The  constitutional  treatment  by  antisyphilitic 
remedies,  even  in  cases  with  a  specific  history,  is  usually 
without  good  results,  and  if  pushed  too  far  may  prove 
harmful.  Obvious  derangements  of  the  alimentary  canal 


334  NEW  GROWTHS 

should  receive  attention,  the  mouth  and  teeth  should  be 
looked  after,  and  the  use  of  alcohol  and  tobacco  and  highly 
spiced  foods  prohibited. 

In  mild  cases,  slightly  astringent  washes  may  be  pre- 
scribed, or  the  patient  may  hold  in  his  mouth,  from  time  to 
time,  a  lozenge  made  of  the  Australian  red  gum. 

Under  such  management  some  cases  recover  or  else  give 
no  further  trouble.  Treatment  by  caustics  or  other  heroic 
measures  should  be  avoided,  but  exceptionally  cracks  and 
ulcers  may  be  lightly  touched  with  lunar  caustic  or  tincture 
of  iodine.  Suspicious  growths  or  indurated  ulcers  should  be 
removed  by  surgical  means. 

It  is  fair  to  say  that  some  physicians  advise  more  or  less 
energetic  treatment,  especially  when  considerable  thicken- 
ing has  occurred. 

Vidal  recommended  a  20  per  cent,  chromic  acid  solution, 
and  Sherwell  advises  the  application  of  liquor  hydrargyri 
nitratis  for  fifteen  or  twenty  minutes  at  a  time,  after  which 
it  is  neutralized  with  bicarbonate  of  sodium.  The  rest  of 
the  mouth  is  protected  with  absorbent  cotton.  Leistikow 
prescribes  this  paste: 

1$ — Terrae  silicise 5jss 

Resorcini oiij 

Adipis 3ss — M. 

The  remedy  is  to  be  applied  with  a  piece  of  wood  several 
times  a  day,  especially  after  meals  and  at  bedtime.  After 
a  season  the  use  of  the  paste  becomes  painful,  when  it  is 
to  be  stopped  and  the  mouth  washed  quite  frequently  with 
borax-peppermint  water,  and  balsam  of  Peru  applied  to 
the  patch. 

Bockhardt  applies  balsam  of  Peru  daily,  or  every  other 
day,  and  orders  that  the  mouth  be  washed  out  one-half 
dozen  or  more  times  a  day  with  a  \  to  3  per  cent,  salt 
solution.  Abstinence  from  tobacco  must  be  absolute. 
Pencilling  on  the  affected  parts  a  20  per  cent,  solution  of 
iodide  of  potassium  has  also  been  suggested.  Stelwagon 
thinks  highly  of  the  galvanocautery  in  appropriate  cases 


KERATOSIS  FOLL1CULARIS  335 

The  x-ray  has  been  used  in  the  treatment  of  leucoplakia 
with  varying  success.  Our  own  experience  has  not  been 
altogether  satisfactory. 


KERATOSIS  FOLLICULARIS  (DARIER'S  DISEASE). 

Description. — Keratosis  follicularis  is  characterized,  as 
regards  its  lesions,  by  the  appearance  of  pin-head-sized, 
solid  papules  that  in  the  beginning  differ  little  in  color  from 
the  rest  of  the  skin,  but  later,  after  increasing  in  size,  they 
take  on  a  darker  hue,  and  are  covered  with  a  hard,  grayish 
or  blackish  scale  that  dips  down  into  the  duct  of  the  pilo- 
sebaceous  follicle. 

The  lesions  may  be  found  upon  any  part  of  the  body, 
but  certain  localities,  such  as  the  face,  scalp,  breast,  and 
inguinal  and  hypogastric  regions  are  preferentially  attacked. 
In  a  large  number  of  cases  the  initial  point  of  attack  was  the 
head  and  face,  thence  extending  downward. 

Corresponding  with  the  deepening  in  color  and  increase 
in  the  size  of  the  lesions,  they  also  tend  to  run  together, 
and  display  here  and  there  spine-like  projections  and  even 
horny  excrescences.  In  certain  localities,  such  as  behind 
the  ears,  and  in  the  hypogastric  and  inguinal  regions,  the 
eruption  may  take  on  a  papillomatous  aspect  and  ulcera- 
tion  may  occur.  On  the  scalp,  the  disease  suggests  a 
seborrheal  eczema.  The  backs  of  the  hands  also  show 
verrucous  elevations,  and  sometimes  plaques  of  thickened, 
scaly  skin,  and  the  palms  and  soles  may  be  affected,  though 
to  a  less  degree.  The  nails  are  thickened  and  furrowed, 
and  quite  brittle.  The  disease,  with  periods  of  quiet  and 
stages  of  exacerbation,  progresses  slowly  but  surely  until 
most  of  the  body  is  involved.  Itching  is  usually  slight,  but 
pain  may  occur  from  the  presence  of  ulcerations.  A  dis- 
agreeable odor  is  often  to  be  noted.  The  general  health 
is  usually  good. 

The  disease  makes  its  appearance  before  the  sixteenth 
year;  in  a  patient  seen  by  one  of  us  it  was  first  noticed  at 


336  NEW  GROWTHS 

the  sixth  year.  Darier's  idea  that  the  disease  is  due  to 
psorosperms  has  now  been  abandoned,  and  it  is  today 
regarded  as  a  keratosis  "or  modified  cornification  of  the 
epithelial  layers  having  its  seat  in  the  mouths  of  the 
pilosebaceous  ducts"  (Stelwagon). 

Prognosis. — The  prognosis  is  unfavorable  as  regards  the 
cure  of  the  disease,  but  the  patient's  general  health  is  not 
materially  affected. 

Treatment. — The  treatment  of  this  affection  has  hereto- 
fore been  very  unpromising.  Locally,  it  consists  for  the  most 
part  in  the  taking  of  warm  alkaline  baths,  and  the  applica- 
tion of  such  remedies  as  salicylic  acid,  resorcin,  pyrogallol, 
sulphur,  etc.  Leredde  mentions  a  case  that  was  apparently 
cured  by  the  vigorous  use  of  resorcin  and  sulphur  pastes 
and  lotions.  Recently  Mook  has  reported  favorably  upon 
the  employment  of  the  x-rays.  In  a  patient  under  the  care 
of  one  of  us  this  form  of  treatment  was  begun,  but  the 
patient,  a  case  from  the  clinic,  disappeared  before  we 
could  come  to  any  conclusion  as  to  the  results.  We  are 
convinced,  however,  that  this  will  be  the  treatment  of 
choice  in  the  future.  Inasmuch  as  in  the  case  just  men- 
tioned the  condition  almost  disappeared  each  winter,  it  is 
possible  that  residence  in  a  northern  climate  might  some- 
times be  beneficial. 


KERATOSIS  FOLLICULARIS  CONTAGIOSA. 

Description. — H.  G.  Brooke,  under  this  title,  has  called 
attention  to  an  abnormality  of  cornification,  which  he  has 
observed  as  a  contagious  affection  in  children.  The  disease 
appeared  on  the  extensor  surfaces  of  the  limbs,  the  neck 
and  trunk,  but  also  extended  to  other  parts. 

In  the  involved  regions  there  was  a  general  thickening 
of  the  skin,  with  exaggeration  of  the  natural  lines.  Within 
the  areas  thus  formed,  small  black  spots  were  visible,  which 
finally  became  raised  into  papules,  and  the  whole  of  the 
aMVcted  region  took  on  a  dirty  yellow  color.  From  these 


MOLLUSCUM  EPITHELIALE  337 

papules,  in  most  instances,  a  spine  projected,  and  some 
of  them  became  subacutely  inflamed.  In  some  situations, 
instead  of  spines,  the  larger  papules  presented  comedo-like, 
horny  plugs. 

These  features  were  more  or  less  evident  in  all  the  cases, 
and  its  contagious  nature  seems  to  be  beyond  doubt.  The 
process  in  a  hyperplasia  of  the  epithelial  cells  combined 
with  a  modification  of  cornification. 

The  treatment,  which  was  effectual,  consisted  in  inunc- 
tions of  mollin. 


MOLLUSCUM  EPITHELIALE. 

Description. — This  disease  is  also  known  by  the  names  of 
molluscum  sebaceum  and  molluscum  contagiosum.  It  is  a 
very  striking  disorder,  and  once  seen  is  not  to  be  forgotten. 
The  lesions  in  the  beginning  are  very  small,  of  pin-head 
size,  perhaps,  of  a  pinkish  or  whitish  color,  but  in  the 
course  of  weeks  or  months  they  may  get  to  be  as  big  as  a 
pea,  although  exceptionally  they  may  be  somewhat  larger. 
Generally  they  are  sessile,  and  the  skin  over  them  is 
stretched  and  glistening,  giving  the  little  tumors  the 
appearance  of  drops  of  wax.  To  the  touch  they  are  firm, 
but  they  become  softer  as  they  grow  older.  In  most 
instances  the  lesions  are  umbilicated,  with  a  central  spot 
indicating  the  mouth  of  the  follicle.  From  the  central 
aperture  of  larger  tumors  a  milky  or  gruel-like  fluid  may 
be  squeezed.  By  slightly  enlarging  the  orifice,  a  waxy, 
pinkish  mass  may  be  expressed.  The  mollusca  may 
finally  inflame  and  discharge  their  contents  through  sup- 
puration. The  growths  are  usually  few  in  number,  occur 
mostly  in  children,  and  are  chiefly  to  be  found  on  the  face, 
especially  the  eyelids,  cheeks,  and  chin,  but  they  are  also 
met  with  on  the  neck,  breasts,  and  genitals.  Sometimes 
hundreds  of  tumors  have  been  counted,  and  occasionally 
the  lesions  have  been  of  extraordinary  size  (W.  G.  Smith). 
Subjective  symptoms  are  absent. 
22 


338  NEW  GROWTHS 

Molluscum  epitheliale  is  commoner  in  children  than  in 
adults,  and  it  is  said  to  be  more  often  seen  in  females  than 
males. 

It  is  quite  generally  conceded  that  the  disease  is  parasitic 
and  contagious,  although  no  definite  parasite  has  been 
discovered.  At  the  present  time,  most  observers  are  agreed 
that  molluscum  epitheliale  is  not  a  protozoan  disease,  but 
that  the  "molluscum  bodies"  are  the  result  of  changes  in 
the  epithelial  cells. 

Prognosis. — A  radical  cure  may  confidently  be  predicted, 
but  if  the  destruction  is  ineffectual  the  growths  are  prone 
to  reappear. 

Treatment. — The  little  tumors  may  be  slit  up  with  a 
knife,  the  contents  expressed,  and  the  base  touched  with 
nitrate  of  silver.  The  cautery  or  curette  may  be  used. 
Electrolysis  is  also  effectual.  In  some  instances,  an  oint- 
ment of  ammoniated  mercury,  20  to  30  gr.  to  1  oz.,  will 
cause  the  little  tumors  to  disappear.  The  salve  should  be 
applied  with  slight  friction. 


CARCINOMA  CUTIS. 

Description. — Carcinoma  of  the  skin  occurs  as  scirrlius 
and  epithelioma.  Scirrhus  is  rare,  and  is  usually  secondary 
to  some  deposit  in  other  parts,  such  as  the  breast.  This 
form  of  cancer  in  reality  often  affects  the  subcutaneous 
tissue  more  than  the  true  skin.  In  its  etiology  and  anatomy 
it  does  not  differ  from  scirrhus  affecting  other  organs. 
Two  varieties  of  scirrhus  of  the  skin  are  recognized:  the 
lenticular  and  the  tuberose. 

A  melanotic  or  pigmented  carcinoma  is  also  occasionally 
encountered. 

Treatment. — The  treatment  of  these  conditions  is  not 
promising.  When  practicable,  and  in  the  beginning, 
excision  is  demanded.  As  a  rule,  however,  surgical  inter- 
ference is  useless,  the  various  types  tending  to  wide  dis- 
semination. Arsenic  by  the  mouth  or  hypodermically, 


EPITHELIOMA  339 

or  the  Beard  treatment  might  be  tried.  Pusey  has  obtained 
some  symptomatic  cures  with  the  re-rays,  which  had  lasted 
over  five  years  when  reported. 


EPITHELIOMA. 

Description. — The  clinical  appearances  presented  by 
epithelioma  vary  according  to  the  stage  of  the  disease, 
its  situation,  and  its  anatomical  peculiarities.  It  is  usual 
to  describe  these  variations  under  three  heads:  superfi- 
cial epithelioma,  deeply  seated  epithelioma,  and  papillary 
epithelioma. 

The  superficial  form  of  the  disorder  often  first  appears  as 
yellowish,  reddish,  sometimes  waxy  papules  of  the  size  of  a 
pin 's  head  or  larger.  Several  such  papules  or  tubercles  may 
coalesce  to  form  a  small,  lobulated  tumor  over  and  around 
which  dilated  vessels  may  be  seen.  At  other  times  this 
variety  of  epithelioma  may  have  its  origin  in  a  wart,  mole, 
or  flat  infiltration  of  the  skin,  or  seborrheic  patch.  After  a 
variable  time  a  crust  forms  upon  the  lesion,  which,  when 
removed,  exposes  a  shallow,  red,  superficial  ulceration,  the 
edges  and  base  having  a  thin,  though  firm  induration.  The 
growth  may  remain  in  this  condition  for  a  long  period 
before  an  extension  of  the  ulceration  occurs,  which  is  often 
accomplished  by  the  formation  of  a  shallow  ulcer  with  a 
waxy  or  pearl-like,  rolled  border.  The  floor  of  the  lesion 
exudes  a  thick,  varnish-like  secretion,  which  dries  into  a 
fairly  consistent  crust.  As  a  rule,  superficial  epithelioma 
extends  in  depth  only  after  a  long  period,  but,  unchecked, 
it  may  in  time  cause  great  destruction.  In  some  occasional 
cases  a  certain  amount  of  cicatricial  repair  occurs  in  the 
wake  of  the  advancing  disease. 

In  the  earlier  stages,  pain  is  not  pronounced,  but  later  on 
this  symptom  may  add  greatly  to  the  evils  of  the  patient's 
condition.  There  is  no  tendency  to  involvement  of  the 
lymphatics,  the  disease  remaining  wholly  local.  When 
life  is  destroyed  it  is  because  a  vital  organ  has  been  involved, 
or  else  the  patient  sinks  from  gradual  exhaustion. 


340  NEW  GROWTHS 

The  superficial  form  of  epithelioma  occurs  most  often 
on  the  face,  although  it  may  be  found  upon  other  parts  of 
the  body. 

A  certain  clinical  variety  of  superficial  epithelioma  has 
been  called  rodent  ulcer,  and  some  good  authorities  still 
look  upon  it  as  clinically  and  anatomically  distinct. 
Rodent  ulcer  is  to  be  regarded  as  an  epithelioma  which 
presents  the  clinical  peculiarities  of  being  extremely  slow 
in  growth,  not  as  a  rule  painful,  and  with  little  tendency 
to  new  growth  as  compared  to  the  amount  of  destruction. 

The  deep-seated  epithelioma  may  develop  from  the 
superficial  form,  but  more  commonly  it  commences  as  an 
infiltration  set  deep  in  the  skin.  The  growth  may  in  the 
beginning  lie  in  the  subcutaneous  tissue,  or  it  may  project 
above  the  skin  as  a  round  or  flat  or  lobulated  tumor.  The 
skin  over  it  is  reddish  or  purple,  and  dilated  vessels  are 
often  seen  running  over  the  surface.  The  tumor  is  very 
hard  to  the  touch,  and  though  at  first  freely  movable  over 
the  deeper  structures,  in  the  course  of  time  it  becomes 
firmly  adherent.  Ulceration  is  the  ultimate  result  of  the 
morbid  process.  The  appearance  of  the  ulcer  differs  much 
in  different  cases.  Generally  the  edges  are  everted,  irregu- 
lar, infiltrated  and  of  a  livid  color,  while  the  floor  is  uneven 
and  may  be  covered  with  a  crust.  There  is  a  thin,  viscid 
discharge,  which  becomes  purulent  and  offensive  if  the  ne- 
crosis is  rapid. 

The  course  of  this  variety  of  epithelioma  is  much  more 
rapid  than  that  of  the  superficial  form.  The  lymphatics 
become  involved,  cachexia  is  established,  and  the  patient 
dies  in  the  course  of  a  few  months,  or  at  most  at  the  end  of 
three  or  four  years.  This  form  of  epithelioma  is  painful, 
often  severely  so,  from  the  first. 

The  common  sites  for  deep-seated  epithelioma  are  the 
lower  lip,  the  tongue,  and  the  external  genitals,  though  it 
may  occur  upon  any  part  of  the  body. 

In  either  one  of  the  above-described  forms  of  epithelioma 
the  papillae  may  become  greatly  hypertrophied,  giving  to 
the  cancer  a  peculiar  appearance  to  which  the  name 


EPITHELIOMA  341 

papillary  epithelioma  is  applied.  Sometimes  the  enlarged 
papillae  are  present  from  the  first;  this  is  especially  apt 
to  be  the  case  if  the  cancer  has  originated  from  a  wart. 
The  papillary  epithelioma  may  be  sessile  or  pedunculated. 
Its  color  is  usually  a  bright  red,  and  the  tumor  bleeds  easily. 
Between  the  papillae  fissures  form,  from  which  issues  a 
sticky,  sanguinolent  and  offensive  discharge.  The  base 
upon  which  the  papillae  are  situated  is  infiltrated.  In  the 
course  of  time  the  tissue  breaks  down,  with  the  formation 
of  an  ulcer  which  pursues  the  usual  course  of  an  epithe- 
liomatous  ulcer. 

Heredity  plays  a  smaller  part  in  the  etiology  of  cancer 
than  was  at  one  time  suppossd.  Cancers  of  the  skin, 
like  carcinomata  of  other  organs,  are  in  some  way  inti- 
mately associated  with  the  retrogressive  changes  of  declin- 
ing life.  Thus,  rarely  does  an  epithelioma  of  the  skin  occur 
before  the  fortieth  year.1  Epitheliomata  are  prone  to 
form  at  points  which  are  subject  to  constant  irritation; 
epithelioma  of  the  lower  lip  is  common  among  pipe  smokers. 
Certain  occupations  predispose  to  epithelioma,  because 
they  afford  means  for  local  irritation.  We  have  seen  how 
often  epitheliomata  begin  in  warts  and  moles.  Other 
neoplasms,  such  as  cutaneous  horns,  sebaceous  cysts  and 
scars,  are  frequently  the  starting  points  for  these  growths. 

Today  the  idea  that  cancer  is  of  parasitic  origin  is  not 
so  general  as  it  was  some  years  ago.  It  is,  moreover,  evi- 
dent that  for  cancer  to  attack  the  organism  something 
more  than  the  inoculation  of  a  parasite  is  necessary,  namely, 
predisposition. 

Diagnosis. — The  surest  way  of  making  a  diagnosis  of 
epitholioma  is  by  submitting  portions  of  the  tumor  to  a 
microscopic  examination.  Clinically,  epithelioma  must  be 
distinguished  from  lupus,  syphilis,  innocent  papillomata, 

1  Hartzell,  however  (New  York  Medical  Journal,  March  5,  1898), 
reports  a  case  of  epithelioma  (rodent  ulcer)  in  a  boy  of  fourteen  years, 
and  quotes  a  number  of  instances  of  early  attacks  found  in  literature. 
It  would  seem  that  the  so-called  rodent  ulcer  has  a  tendency  to  occur 
earlier  than  other  varieties  of  epithelioma. 


342  -V£»"  GROWTHS 

seborrhea,  and  rhinoscleroma.  Lupus  develops  in  most 
cases  before  the  age  at  which  we  find  epithelioma;  there 
is  no  induration,  the  lesions  are  multiple,  the  discharge  is 
more  purulent,  and  not  sanious  or  offensive,  and  the  apple- 
jelly  nodules  are  usually  to  be  seen  around  the  edges  of 
the  affected  parts. 

Syphilitic  tubercles  and  ulcerative  processes  are  to  be 
differentiated  from  cancer  by  the  history  of  the  case,  the 
absence  of  pain,  and  the  more  rapid  evolution  of  the  lesions. 
Syphilitic  tubercles  are  grouped,  and  ulceration  will  begin 
at  several  points,  the  ulcers  being  punched  out  and  secret- 
ing an  abundant,  yellowish  pus.  The  ^border  of  the 
syphilitic  ulcer  is  not  indurated  as  in  epithelioma. 

It  is  sometimes  difficult,  when  a  wart  has  been  irritated, 
to  say  whether  it  has  become  epitheliomatous,  but  a  safe 
rule  is  to  treat  the  condition  just  as  if  it  were  malignant. 

In  the  early  stage  of  epithelioma,  before  ulceration  has 
occurred,  it  is  possible  to  confound  it  with  seborrhea. 
In  seborrhea  the  skin  is  not  infiltrated,  and  the  crusts  are 
composed  of  dried  sebum  and  epithelial  scales,  which,  when 
removed,  exhibit  distended  sebaceous  follicles.  The  local- 
ized hypertrophy  of  the  skin  called  keratosis  senilis  is  some- 
times very  difficult  to  distinguish  from  epithelioma.  The 
principal  point  of  difference  between  keratosis  and  epithe- 
lioma is  that  epithelioma  is  usually  single,  while  keratosis 
is  often  found  in  more  than  one  place;  as  keratosis  senilis 
is  not  infrequently  the  starting  point  for  epithelioma,  it  is 
of  the  greatest  importance  to  watch  all  cases  of  this  affection 
with  care. 

Rhinoscleroma  occurs  most  often  on  the  upper  lip  and 
about  the  nares — a  site  very  rare  for  epithelioma.  Rhino- 
scleroma  does  not  ulcerate,  but  this  forms  a  comparatively 
early  step  in  the  evolution  of  epithelioma.  Finally,  a 
microscopic  examination  might  reveal  the  bacilli  of  rhino- 
scleroma. 

Prognosis. — In  its  ultimate  outcome,  epithelioma  must 
always  be  looked  upon  as  a  grave  disorder,  although  the 
superficial  and  circumscribed  forms,  if  treated  early  and 


EP1THELIOMA  343 

radically,  may  not  return.  Even  in  more  serious  cases 
efficient  treatment  may  do  much  to  stay  its  progress.  It 
must  also  be  remembered  that  the  march  of  the  disease  is 
often  very  slow,  sometimes  occupying  years ;  but,  again,  the 
onset  may  be  much  more  rapid,  especially  in  the  deep- 
seated  varieties  of  skin  cancer. 

Treatment. — No  internal  treatment  has  as  yet  been  dis- 
covered which  will  arrest  the  progress  of  cancer.  A.  R. 
Robinson,  however,  considers  thyroid  extract  a  valuable 
agent  in  cases  of  single  or  multiple  cancers  of  a  superficial 
character  in  elderly  persons,  and  in  all  persons  with  a 
marked  senile  condition  of  the  skin.  He  is  emphatic  in 
his  belief  that  it  prevents  new  growths  and  also  aids  in 
the  removal  of  those  already  in  existence.  It  is  also  proper 
to  add  that  some  few  authorities  regard  arsenic  favorably, 
although  our  experience  does  not  support  this  view.  In 
the  later  stages  of  the  disease  supporting  measures,  together 
with  anodynes  to  relieve  pain,  must  be  used. 

The  curative  treatment  of  epithelioma  is  wholly  local. 
The  object  to  be  attained  is  the  complete  destruction  of  all 
cancerous  tissues.  That  method  which  accomplishes  this 
result  most  surely,  with  the  least  pain  and  inconvenience 
to  the  patient,  and  with  the  minimum  of  subsequent  deform- 
ity, is  to  be  chosen;  but  it  is  always  to  be  borne  in  mind 
that  no  considerations  of  a  cosmetic  sort  can  ever  excuse 
the  surgeon  from  making  the  destruction  thorough. 

Removal  by  the  knife  has  the  advantages  that  it  is  exact, 
that  it  is  less  painful  than  most  other  methods,  and  that  the 
removal  can  be  accomplished  at  one  operation.  In  regions 
where  sufficient  tissue  can  be  spared  to  ensure  an  incision 
wide  of  the  diseased  area,  it  is  the  ideal  method.  But  ex- 
cision has  certain  drawbacks.  It  is  a  matter  of  guesswork 
how  far  outside  the  apparently  involved  area  the  incision 
must  extend,  as  we  have  no  means  of  determining  the 
distance  to  which  single  cancer  cells  or  groups  of  cells  have 
penetrated  into  the  surrounding  tissues.  If  any  of  these 
cells  be  left,  recurrence  is  very  likely  to  take  place,  especially 
if  primary  union  of  the  wound  occur,  for  by  this  method 


344  A/-;  IK  GROWTHS 

of  healing  any  advantage  to  be  derived  from  the  influence 
of  inflammatory  action  on  the  remaining  cancer  cells  is 
lost.  For  this  reason  many  recommend  that  after  removal 
of  an  epithelioma  the  wound  be  cauterized  and  left  to  heal 
by  granulation.  It  is  a  further  disadvantage  of  the  knife, 
that  by  its  use  no  selective  action  is  exercised,  and  the 
healthy  tissue  inside  the  lines  of  the  incision  is  removed 
along  with  the  diseased.  The  resulting  deformity  is  thus 
greater  than  by  some  other  methods,  and  in  certain  regions, 
such  as  the  nose  or  the  eyelid,  this  is  a  matter  of  no  small 
importance. 

Although  the  curette  has  been  strongly  recommended, 
its  use  is  very  limited.  If  with  the  knife  the  removal  of  all 
the  new  growth  is  a  matter  of  great  difficulty,  it  may  be 
said  to  be  almost  impossible  with  the  curette.  The  curette 
should  be  used  to  prepare  the  way  for  other  treatment,  as  by 
removing  the  softer  or  necrotic  portions  of  a  growth,  so 
that  a  caustic  or  other  remedy  may  act  more  rapidly  and 
thoroughly. 

Caustics  have  long  been  employed  in  the  treatment  of 
cancerous  growths.  It  is  unfortunate  that  they  constitute 
the  principal  means  of  treatment  employed  by  charlatans, 
since  on  this  account  they  have  been  somewhat  neglected 
by  physicians.  Many  chemical  preparations  have  been 
used  for  the  purpose  of  producing  destruction  by  cauteri- 
zation, among  which  may  be  mentioned  arsenic,  caustic 
potash,  to  the  advantages  of  which,  in  superficial  cases, 
Van  Harlingen  has  again  recently  called  attention ;  chloride 
of  zinc,  the  stronger  mineral  acids,  trichloracetic  acid, 
carbolic  acid,  acid  nitrate  of  mercury  (a  special  favorite 
with  us),  ethylate  of  soda,  lactic  acid,  and  pyrogallic  acid. 
Nitrate  of  silver  is  only  mentioned  to  be  condemned  as 
inefficient.  The  use  of  a  caustic  agent  has  the  advantage 
that  the  area  of  action  is  not  limited  to  the  line  of  appli- 
cation, as  is  the  case  when  the  knife  is  used.  The  inflam- 
matory reaction  influences  the  tissues  to  a  greater  or  less 
distance  around  the  area  to  which  it  is  actually  applied. 

Thus  with  a  properly  selected  caustic  we  can  accomplish 


EPITHELIOMA  345 

destruction  of  the  diseased  tissue  with  small  loss  of  the 
unaffected  portions.  Robinson1  believes  that  during  the 
action  of  a  caustic  a  toxalbumin  is  formed  which  acts  in 
an  unfavorable  manner  upon  the  cause  of  cancer.  He 
supports  this  opinion  by  a  reference  to  the  decrease  in  size 
of  glands  at  a  distance  from  the  growth,  which  were  pre- 
sumably the  seat  of  secondary  infection,  which  he  has 
observed  after  the  use  of  a  caustic.  Some  caustic  agents, 
such  as  arsenic  and  pyrogallic  acid,  have  a  selective  affinity 
for  cancerous  tissue,  destroying  it,  while  the  normal  parts 
are  left  comparatively  unaffected.  The  caustics  which  are 
most  valuable  are  arsenious  acid,  chloride  of  zine,  and 
caustic  potash. 

Arsenic  is  used  in  the  form  of  a  paste  made  by  rubbing 
together  equal  parts  of  acacia  and  arsenious  acid  and  add- 
ing enough  water  to  make  the  mass  of  the  consistency  of 
butter.  The  paste  should  be  freshly  prepared  each  time 
it  is  used.  Walker  suggests  the  following  formula: 

1$ — Acidi  arseniosi, 

Acacias  pulv aa     3ij 

Orthoform 3ss — M. 

It  should  be  spread  on  a  piece  of  cloth  large  enough  to 
extend  beyond  the  elevated  margin  of  the  tumor.  This 
may  be  held  in  place  in  contact  with  the  tumor  by  means 
of  strips  of  adhesive  plaster.  Marsden  originally  recom- 
mended that  a  space  not  larger  than  one  square  inch 
should  be  attacked  at  a  time,  but  Robinson  has  applied  the 
paste  to  a  much  larger  surface  and  has  not  observed  any 
injurious  effects.  Arsenic  is  not  a  suitable  remedy  about 
the  lips  and  mucous  membranes  on  account  of  the  danger 
of  absorption.  The  application  of  the  paste  is  usually 
accompanied  by  considerable  pain.  The  remedy  should 
be  allowed  to  act  continuously  for  from  fourteen  to  twenty 
hours.  If  the  pain  is  not  too  great  and  the  evidences  of 
inflammatory  reaction  not  severe,  the  use  of  the  paste 
should  be  continued  the  full  limit  of  time,  as  it  has  been 

1  International  Journal  of  Surgery,  July,  1892. 


346  XE\V  GROWTHS 

found  that  it  takes  arsenic  longer  than  this  to  destroy  the 
normal  skin.  If  upon  removal  of  the  drug  all  the  cancer 
mass  seems  to  be  necrosed,  and  there  is  considerable 
inflammation  extending  around  it,  the  action  may  be 
regarded  as  sufficient.  If  such  a  result  is  not  secured, 
the  caustic  must  be  reapplied  until  the  desired  effect  is 
obtained. 

After  sufficient  poulticing  to  remove  the  eschar  the  result- 
ing wound  should  be  dressed  with  a  soothing  salve.  If  it 
heal  promptly  from  all  sides,  the  treatment  may  be  con- 
sidered successful ,  but  if  at  any  portion  the  healing  be  slow, 
or  if  unhealthy  granulations  spring  up,  the  paste  must  be 
again  applied  to  that  portion. 

Chloride  of  zinc  may  be  used  in  the  stick  form,  in  solu- 
tion, or  as  a  paste.  The  use  of  this  caustic  is  attended  with 
more  pain  than  follows  the  application  of  arsenic.  In  the 
stick  form  chloride  of  zinc  is  especially  suitable  for  cauter- 
izing epitheliomata  at  the  inner  canthus  or  on  the  lids,  as 
its  action  is  easily  controlled.  In  solutions  of  the  strength 
of  50  per  cent,  or  less,  it  is  of  great  service  in  cauterizing 
wounds  after  excision  of  a  growth.  As  a  paste,  zinc  chloride 
is  one  of  the  most  reliable  agents  for  the  destruction  of 
epitheliomata.  Bourgard's  formula  for  the  paste  is: 

1$ — Farina;  tritici, 

Amyli aa  5j 

Acidi  arseniosi gr.  viij 

Hydrarg.  sulph.  rub gr.  xl 

Ammonii  muriat gr.  xl 

Hydrarg.  bichloridi gr.  iv 

Zinci  chloridi  cryst oj 

Aquae  bullientis       .      .      .    ~.      .      .      .  5jss — M. 

All  the  ingredients  except  the  zinc  and  water  are  finely 
ground  together.  The  zinc  is  then  dissolved  in  the  water, 
and  this  is  poured  upon  the  powder,  stirring  all  the  time. 
The  paste  after  standing  twenty-four  hours  is  ready  for  use. 

The  paste  is  to  be  spread  on  cotton  or  linen  cloth  and 
applied  to  the  epithelioma  for  twenty-four  hours.  If  all 
the  growth  does  not  seem  to  be  destroyed  at  the  end  of 
this  time,  the  paste  is  to  be  reapplied.  On  account  of  the 


SPITHEL10MA  347 

severe  pain  caused  by  the  chloride  of  zinc  it  is  well  to  add 
cocaine  to  the  paste.  The  treatment  of  the  resulting 
wound  is  the  same  as  after  the  use  of  arsenic.  Czerny  and 
Trunecek  highly  recommend  a  mixture  of  arsenious  acid 
with  alcohol  and  water  in  the  following  proportions: 
Powdered  arsenious  acid,  1  gm. ;  ethylic  alcohol  and  dis- 
tilled water,  of  each  75  gm.  The  growth  is  carefully  cleaned, 
and  if  a  few  drops  of  blood  appear,  so  much  the  better; 
the  arsenical  mixture  is  then  shaken  and  applied  all  over  the 
ulcer  with  a  brush.  A  little  pain,  lasting  a  few  hours, 
usually  follows.  The  next  day  the  ulceration  is  seen  to  be 
covered  by  a  crust,  but  the  application  is  made  daily  over 
the  scab,  causing  it  to  turn  from  yellow  to  brown  and  at 
hist  to  become  almost  black  in  color.  The  same  treatment 
is  continued  regularly  until  the  crust  becomes  readily 
detached,  or  until  it  is  held  in  place  by  a  few,  thin,  fibrous 
bands  that  may  be  cut  through  and  the  scab  removed. 
When  the  first  crust  comes  away  the  ulcer  is  again  painted 
with  the  same  solution.  If  only  a  thin,  yellowish  pellicle 
results  it  may  be  assumed  that  all  of  the  cancerous  tissue 
has  been  removed;  but  if  a  thick,  adherent  crust  forms, 
the  treatment  must  be  continued.  The  thicker  the  crust 
the  more  energetic  must  be  the  application,  even  to  the 
extent  of  employing  a  1  to  100  and  even  a  1  to  80  solution. 

French  authors  formerly  recommended  dusting  the 
surface  of  the  sore  with  potassium  chlorate  in  powder,  or 
applying  a  5  per  cent,  solution.  Bergeron  and  Vidal 
revived  the  method  in  modified  form.  Believing  that  the 
agent  acts  only  on  raw  tissue,  they  packed  the  surface  with 
the  chlorate  after  curetting.  As  the  attendant  pain  is  con- 
siderable, the  application  is  preceded  by  the  use  of  cocaine. 

Caustic  potash,  in  the  stick  form,  is  the  caustic  most 
highly  prized  by  many  authors.  The  advantage  of  the 
remedy  is  that  it  acts  rapidly,  so  that  considerable  destruc- 
tion is  quickly  produced.  Its  application  is  quite  painful. 
Caustic  potash  has  no  selective  action,  destroying  both 
normal  and  diseased  tissues  with  equal  facility.  When  it 
is  important  to  save  tissue  it  should  not  be  used.  On  ac- 


348  v/;ir  GROWTHS 

count  of  the  difficulty  of  limiting  the  action  of  this  caustic 
it  should  not  be  employed  about  the  eye  or  in  the  vicinity 
of  large  vessels  or  other  important  structures. 

Pyrogallic  acid  has  had  many  warm  advocates.  Its 
action  is  slow  and  painless.  It  may  be  used  in  the  form  of 
an  ointment: 

1$ — Acidi  pyrogallici oij 

Emplast.  plumbi 3j 

Cerati  resmse  co 3v — M. 

This  is  spread  on  cloth  and  kept  constantly  applied  for 
from  a  day  to  a  week  according  to  the  destruction  neces- 
sary. The  acid  has  a  selective  action,  attacking  the  healthy 
tissues  only  at  their  surface.  It  is  a  good  remedy  with 
which  to  follow  the  use  of  the  curette. 

The  remedies  mentioned  constitute  the  most  valuable  of 
the  caustics.  Most  of  the  others  are  not  sufficiently  destruc- 
tive in  their  action,  and  are  dangerous  because  they  often 
serve  rather  as  stimulants  than  as  caustic  agents. 

Electricity  may  be  used  in  the  treatment  of  epithelioma, 
either  as  the  galvanocautery  or  as  the  electrolytic  needle. 
The  galvanocautery  detroys  the  part  to  which  it  is  applied, 
and  has  no  advantages  over  the  knife  except  that  there  is  a 
slight  amount  of  inflammatory  reaction  following  its  use, 
and  that  the  operation  is  bloodless.  The  electrolytic 
needle  affords  a  valuable  method  of  treatment  when  a 
small  epithelioma  is  to  be  destroyed,  especially  about  the 
eyelid  or  other  part,  where  the  destructive  method  used 
must  be  wholly  within  the  control  of  the  operator.  The 
apparatus  employed  is  that  described  under  Nsevus  Vas- 
cularis.  A  rather  stout  needle  is  used,  and  this  is  thrust 
under  the  infiltrated  base  of  the  tumor,  entering  in  healthy 
skin  on  one  side  and  coming  out  through  healthy  skin  on 
the  other.  The  needle  is  thus  passed  from  all  sides  until 
a  complete  destruction  of  the  growth  is  secured.  The 
necrosed  mass  may  be  left  to  separate  by  itself,  or  it  may 
be  at  once  scraped  away  and  the  raw  surface  touched  wita 
chromic  acid  that  has  been  fused  on  the  point  of  a  probe. 
This  is  the  procedure  advised  by  Jamieson  after  curetting, 
a  plan  that  we  can  highly  recommend. 


EPITHELIOMA  349 

After  the  wound  has  had  time  to  get  rid  of  the  slough  it 
should  be  carefully  inspected,  and  if  any  suspicious  portions 
are  seen  these  must  be  destroyed.  It  has  seemed  to  us  that 
the  action  of  electrolysis  is  not  confined  to  the  tissues 
actually  destroyed,  but  extends  to  parts  apparently  not 
injured,  causing  here  perhaps  the  death  of  the  specific 
cells,  which  are  more  readily  injured  than  their  normal 
neighbors. 

While  the  trypsin  treatment  introduced  by  Beard,  of 
Edinburgh,  has  not  so  far  yielded  the  results  confidently 
predicted  by  its  author,  yet  a  few  reliable  observers  have 
reported  cures  so  remarkable  as  to  justify  further  trial. 
For  an  exposition  of  the  startling  but  fascinating  embryo- 
logical  theories  which  suggested  the  method,  the  curious 
reader  may  turn  to  the  London  Lancet  for  1902-'03  and 
1904.  Si  non  e  vero,  e  ben  trovato.  The  points  in  Beard's 
contention  bearing  on  malignancy  are  chiefly  these:  That 
carcinoma  and  sarcoma  arise  from  the  development  of 
aberrant  germinative  cells — not  a  la  Cohnheim,  of  the 
embryo,  but  of  the  trophoblast,  from  a  minute  portion  of 
which  the  embryo  arose.  Your  cancer  is,  therefore,  your 
included  twin  brother.  That  the  intracellular  digestive 
processes  of  a  malignant  growth  are  in  kind  the  same  as 
those  of  the  trophoblast,  that  is,  due  to  pepsin,  or,  what  is 
the  same  thing,  "malignin,"  in  an  acid  medium,  and  not, 
as  in  somatic  tissues,  trypsin  and  an  alkaline  medium. 
That  the  cure  of  cancer  or  of  sarcoma,  therefore,  consists 
in  substituting  tryptic  for  peptic  intracellular  digestion. 
Trypsin  is,  therefore,  to  be  given  in  every  possible  way. 
Messrs.  Fairchild  Bros.  &  Foster  furnish  the  agent  in 
the  various  forms  required,  "injectio  trypsini"  for  hypo- 
dermic use;  "holadin,"  containing  the  three  pancreatic 
enzymes,  for  administration  by  the  mouth,  and  "lotio 
pancreaticum,"  for  local  application  diluted  with  3  parts 
of  sterile  water. 

Shaw-McKenzie,  in  his  book  on  The  Treatment  of 
Cancer,  devotes  considerable  space  to  the  treatment  by 
injections  of  a  solution  of  soap.  The  solution  used  contains 


350  NEW  GROWTHS 

8  or  10  per  cent,  of  soap  in  water.  He  is  not  clear  as  to  the 
particular  soap  used,  a  superfatted  soap  being  preferable. 
Subcutaneous  injections  are  made  in  the  region  of  the 
growth  (sometimes  underneath  it),  beginning  with  5  minims 
and  progressing  to  1  drachm.  The  injection  is  somewhat 
painful.  He  claims  a  very  favorable  result,  the  discharge, 
odor,  and  pain  being  in  his  cases  almost  invariably 
abolished  and  in  a  good  number  complete  disappearance 
of  or  marked  diminution  in  the  lesion  being  obtained.  He 
employs,  internally,  in  conjunction,  a  preparation  of  ox- 
bile,  which  he  pushes  to  the  limit  of  tolerance. 

Webb,  of  Australia,  quoted  in  his  book,  has  obtained 
similar  results. 

Cataphoresis. — L.  Jones  (British  Medical  Gazette,  Febru- 
ary 16,  1907)  describes  a  method  by  which  he  has  obtained 
cures  of  rodent  ulcers  within  two  or  three  weeks  after  a 
single  application.  To  the  positive  pole  of  a  galvanic  bat- 
tery he  connects  a  zinc  rod  surrounded  by  several  layers  of 
lint  moistened  in  a  solution  of  zinc  sulphate.  This  is 
applied  to  the  ulcer  while  the  negative  electrode  is  applied 
to  any  other  part.  5  to  10  ma.  are  used  for  three  minutes. 

J.  Hall  Edwards  uses  zinc  or  zinc-mercury  electrodes 
and  considers  it  one  of  the  best  methods  of  rendering  the 
ulcer  aseptic. 

The  X-rays. — To  America  belongs  the  chief  praise  for 
the  introduction  and  development  of  the  or-rays  in  the 
treatment  of  cancer,  for  although  the  first  cure  was  re- 
corded by  Stenbeck,  of  Stockholm,  the  method  came  into 
extended  use  here  before  being  taken  up  by  our  European 
confreres.  It  is  today  everywhere  recognized  as  the 
method  of  election  in  certain  cases.  What  cases  are  these  ? 

Choice  of  Cases. — The  little  pearl-button  epithelioma- 
tous  nodule  can  be  removed  by  the  rays,  but  at  a  useless 
expenditure  of  time.  We  possess  much  more  rapid  and 
simpler  methods,  such  as  electrolysis,  or  the  galvanic  or 
other  cautery,  preceded  or  not  by  curetta^e. 

The  lesion  of  all  others  which  gives  the  most  brilliant 
results  with  the  rays,  and  in  the  treatment  of  which  they 


KTITHELIOMA  351 

have  won  their  most  brilliant  triumphs,  is  the  "rodent 
ulcer."  In  dealing  with  these  growths  one  may  feel 
almost  sure  of  success,  but  even  here  absolute  certainty 
is  unjustifiable.  One  of  us  failed  after  the  most  thorough 
and  persistent  trial  in  such  a  case,  which  differed  nowise 
clinically  from  others  which  rapidly  proceeded  to  a  cure. 
We  believe  that  certain  differences  exist  in  these  cases, 
discoverable  only  by  their  refusal  to  respond  to  treatment. 
We  can  endorse  Whitfield's  observation,  that  the  rays 
usually  fail  where  bone  has  been  eroded.  Actively  spread- 
ing cases,  in  which  the  ulcerating  edge  is  at  most  points 
sharply  cut  out  in  the  apparently  healthy  skin,  with  only 
here  and  there  broken  arcs  of  dyke-like  border,  do  not 
so  often  yield  good  results  as  do  the  more  sluggish  cases. 
Many  of  these  cases,  however,  eventually  heal.  Others 
do  well  for  a  time  and  then  break  down  and  spread  more 
rapidly  than  before.  It  sometimes  happens  that  the  ulcer 
closes  over  all  but  one  little  depressed  area,  which  remains 
obstinate  for  a  time,  and  then  becomes  the  centre  of  a  new 
and  rapid  destruction. 

Papillary  epitheliomata  rarely  do  as  well  as  the  flatter 
neoplasms.  Of  2  such  treated  by  one  of  us,  clinically 
similar,  1  yielded  a  lasting  good  result,  while  the  other 
continued  to  grow  in  spite  of  active  raying  and  was  finally 
removed  by  the  knife. 

It  is  a  safe  rule  to  proceed  surgically  against  cancers 
which  project  much  above  the  general  surface,  and  to  com- 
mence  raying  the  site  a  few  days  later  without  waiting  for 
the  wound  to  close  over. 

Large,  fungating  growths,  and  the  deep,  infiltrating  kind, 
should  only  be  treated  by  radiotherapy  as  a  last  resort, 
lesions  about  mucocutaneous  orifices  should  be  treated 
by  the  rays  whenever  practicable,  as  this  method  affords  the 
best  cicatrices.  Kpithelioma  of  the  lip  is  generally  refrac- 
tory, although  one  such  case  gave  us  an  excellent  result 
with  no  recurrence  for  now  five  years. 

In  conclusion,  it  may  be  said  that  the  use  of  the  rays 
to  the  exclusion  of  surgical  methods  is  justifiable  in  two 


352  NEW  GROWTHS 

groups  of  cases,  namely,  relatively  mild  forms  at  one 
extreme,  and  inoperable  cases  at  the  other. 

Raying  after  ablation  to  ensure  against  possible  recur- 
rence is  always  proper,  although  not  always  necessary  in 
the  case  of  quasimalignant  types  when  the  surgical  part 
of  the  work  has  been  thoroughly  done. 

Technique. — A  brisk  curetting  without  attempting  to 
remove  all  the  ramifications  of  the  growth,  as  advised  by 
Stelwagon  and  Belot,  is  probably  to  be  recommended  as 
a  time-saving  measure  in  all  sclerosed  lesions. 

As  to  quality  and  intensity  of  rays,  anticathode  distance, 
duration,  and  intervals  of  sittings,  etc.,  the  widest  differ- 
ences of  technique  have  yielded  good  results,  although 
some  methods  are  far  speedier  than  others,  and  again  the 
best  methods  have  at  times  failed.  Every  operator  after 
a  time  develops  a  technique  of  his  own,  his  degree  of  suc- 
cess being  probably  less  dependent  upon  easily  stated 
constants  than  upon  close  watchfulness,  unremitting 
caution,  and  that  quick  recognition  of  faint  indications 
which  comes  with  long  familiarity.  Nevertheless,  a  knowl- 
edge of  the  formulas  employed  by  the  acknowledged  masters 
of  the  art  is  of  the  highest  utility. 

Pusey  gives  "exposures  of  from  five  to  fifteen  minutes' 
duration  with  the  wall  of  the  tube  at  a  distance  of  two  to 
six  inches  from  the  lesion."  These  exposures  he  repeats 
"from  two  to  six  times  weekly."  He  uses  a  relatively 
small  amount  of  the  rays — just  enough  to  cause  a  yellowish- 
green  glow  in  the  tube. 

Stelwagon  gives  five-minute  exposures  at  10  to  12  inches 
twice  a  week  for  the  first  fortnight.  If  this  produces  neither 
reaction  nor  amelioration,  he  gives  three  exposures  a  week 
for  ten  minutes  at  8  inches.  If  there  be  still  no  response, 
the  time  is  gradually  increased  to  fifteen  or  twenty  minutes, 
and  the  distance  decreased  to  5  inches.  Treatment  is 
suspended  on  the  appearance  of  reaction.  This  is  virtually 
the  plan  we  have  hitherto  followed.  According  to  him 
"it  is  not  a  good  plan  to  use  a  tube  of  the  same  degree 
of  vacuum  throughout;  otherwise  some  possible  deeper- 


EPITHELIOMA  353 

lying  morbid  tissu?  may  escape  its  favorable  action."  He 
begins  the  seance  with  a  vacuum  equal  to  a  ^-inch  spark, 
and  then  does  away  with  the  regulator,  allowing  the  vacuum 
to  rise  slightly. 

Beclere  obtained  a  cure  in  a  large  vegetating  epitheli- 
oma  of  ten  years'  duration,  in  the  temporomaxillary  region 
in  a  man  of  seventy,  in  thirteen  sittings,  4  to  5  H.  at  a 
sitting,  with  rays  of  medium  penetration.  Three  sittings 
were  given  the  first  week,  nine  at  intervals  of  a  week,  and 
one,  two  and  one-half  weeks  later. 

Belot  formulates  the  following  rules : 

1.  To  cause  absorption,  in  one  or  two  seances,  of  the 
largest  dose  compatible  with  the  integrity  of  the  tissues. 

2.  To  wait,  before  proceeding  farther,  for  the  phenomena 
of  reaction  to  appear,  and  if  these  are  violent  to  wait  longer 
until  they  disappear. 

In  an  ulcerated  lesion  with  raised  margins  he  gives  8  to 
10  H.  in  one  or  two  consecutive  seances,  including  a  healthy 
strip  j  cm.  in  breadth,  and  then  waits  two  or  three  weeks. 
A  second  dose  of  7  or  9  H.  is  then  given,  followed  by  a 
similar  interval,  and  a  third  dose  of  5  or  6  H.  if  the  state  of 
the  skin  permits  it. 

If  the  lesion  be  not  ulcerated  he  begins  with  a  smaller 
dose,  7  to  8  H.,  at  two  to  three  weeks  interval,  or  4  to  5  H. 
at  intervals  of  a  week  or  ten  days.  He  finds  that  cases  that 
long  remain  refractory  at  the  latter  dose  sometimes  begin 
to  heal  as  soon  as  the  former  dose  is  employed.  We  have 
all  observed  similar  instances. 

The  use  of  massive  doses  at  long  intervals  is  apparently 
gaining  in  favor  in  Paris  and  Vienna,  and  with  some  Ameri- 
cans, although  most  of  the  latter  adhere  to  a  more  tentative, 
but  probably  safer  plan,  and  employ  far  smaller  doses. 
\\e  recommend  the  latter  method  in  any  event  to  those 
who  are  not  thoroughly  familiar  with  this  agent,  which  is 
powerful  for  good  and  for  ill. 

Most  operators  employ  soft  tubes  in  malignancy  at  the 
surface,  although   Freund,  Crocker,  and  Morton  employ 
hard  tubes.    Sequeira  still  uses  tubes  sparking  at  from  4  to 
5  inches. 
23 


354  NEW  GROWTHS 

Many  of  the  continental  Europeans  seek  from  the  first 
to  set  up  a  brisk  dermatitis.  Most  Americans,  however, 
are  satisfied  with  a  mild  erythema,  while  a  number  have 
published  cures  obtained  without  any  visible  reaction,  to 
which  testimony  we  can  add  our  own. 

Morton  suggests  increasing  the  fluorescence  of  the  tissues 
by  the  administration  of  quinine,  esculin,  or  fluorescin. 

Clinical  Effects  of  the  Rays. — Cutaneous  epithelioma  is 
rarely  a  painful  disease.  When  pain  exists,  however,  it 
is  generally  relieved,  often  at  the  first  sitting.  In  rare 
instances  the  contrary  of  this  obtains.  In  a  large,  spread- 
ing rodent  ulcer  ending  fatally  by  exhaustion,  one  of  us 
observed,  on  several  occasions,  such  an  increase  of  pain 
during  irradiation  as  to  force  an  interruption  of  the  sitting. 
Burdick,  Butler,  Coley,  Hall  Edwards  and  Pusey  have 
witnessed  the  same  phenomenon.  Discharge  is  at  first 
sometimes  increased,  but  soon  again  diminishes.  Odor 
usually  disappears.  Hemorrhage,  when  present,  is  mark- 
edly lessened.  In  favorable  cases,  either  with  or  without  a 
preceding  erythema,  one  notices  a  cleaning  off  and  soften- 
ing of  the  sore.  The  appearance  of  the  base  begins  to 
approximate  to  that  of  granulation  tissue,  or,  if  the  lesion  be 
raised,  flattening  becomes  apparent.  Soon  the  growth 
begins  to  lessen  in  all  its  diameters,  and,  if  ulcerated,  to 
fill  up  from  the  base,  until  there  is  left  a  granulating  surface, 
level  with  the  surrounding  surface,  which  soon  skins  over. 
A  tendency  to  break  down  again  in  spots  is  of  evil  import, 
but  does  not  always  mean  ultimate  failure.  Satellite 
adenopathy  when  present  often  disappears,  a  most  sig- 
nificant fact,  proving  that  glandular  enlargement  does  not 
always  mean  involvement  in  the  malignant  process,  but 
may  be  due  to  simple  septic  absorption. 

Results. — Compiling  returns  from  both  European  and 
American  sources,  covering  a  large  number  of  cases  of  all 
forms  of  cutaneous  epithelioma,  shows  about  57  per  cent, 
of  cures.  The  truth,  however,  would  be  represented  by  a 
higher  figure,  since  it  is  certain  that  at  least  some  of  those 
reported  as,  "improved"  and,  "still  under  treatment," 


EPITHELIOMA  355 

were  ultimately  cured.  Limiting  the  investigation  to 
reports  of  the  last  two  or  three  years  would  doubtless  give 
a  still  better  showing,  whereas  the  proportion  of  cures 
among  the  rodent-ulcer  type,  in  the  hands  of  skilled  opera- 
tors, would  approximate  90  per  cent.  Pusey  reports,  of  69 
cases,  58,  or  84  per  cent.,  remaining  well  after  from  one- 
half  to  two  and  one-half  years,  that  is,  "  symptomatically 
cured;"  3  "practically  successful."  Including  these  with 
the  58  gives  88  per  cent,  of  cures.  The  remaining  8  cases 
were  improved. 

We  may  safely  assert  (1)  that  the  majority  of  cases 
are  at  least  temporarily  cured;  (2)  that  recurrence  is 
less  frequent  than  after  any  other  method;  (3)  that  the 
cosmetic  effect  is  the  best  obtainable,  and  in  certain 
situations,  such  as  near  the  natural  orifices,  incomparably 
superior  to  those  secured  in  any  other  way. 

On  the  other  hand,  recurrences  are,  perhaps,  more  fre- 
quent than  was  at  first  supposed,  although  some  of  our 
cases  have  shown  no  return  after  five  years.  Others 
relapsed  after  a  few  months. 

Changes  Effected  in  the  Growth. — The  cells  of  a  malig- 
nant growth,  while  proliferating  more  actively  than  those 
of  normal  tissue,  are  inferior  in  vitality,  and,  therefore, 
yield  more  readily  to  the  various  physical,  chemical,  or 
other  noxa  employed  in  therapeusis.  Their  behavior 
toward  the  re-rays  is  no  exception  to  this  rule.  The  studies 
of  Beclere,  Perthes,  Beck,  Pusey,  and  others  show  that  the 
results  obtained  are  not  due  to  inflammatory  reaction, 
which  may,  therefore,  be  safely  avoided.  The  two  impor- 
tant things  observed  are  obliterating  endarteritis  and 
cellular  necrosis.  The  latter  of  these,  says  Ellis,  is  not 
dependent  upon  the  former,  but  they  proceed  simultane- 
ously. 

Pusey's  findings  are  in  part  as  follows:  "Examination 
of  superficial  neoplastic  tissues  show  that  at  the  beginning 
of  the  treatment  only  the  cells  at  the  circumference  of  the 
diseased  foci  are  attacked. 

"Their  outline  becomes  indistinct,  and  the  nuclei  break 


356  NEW  GROWTHS 

up.  The  scattered  nuclear  debris  is  faintly  stained  by 
hematoxylin. 

"The  cells  exhibit  various  stages  of  degeneration,  and 
disappear  gradually  by  a  process  of  cytolysis,  which  is 
followed  by  an  absorption  of  the  debris.  The  small  vessels, 
which  are  in  close  relation  with  the  tumor,  are  obliterated 
by  a  process  of  endarteritis. 

"The  cure  is  completed  by  the  absorption  of  the  diseased 
cells,  and  their  replacement  by  connective  tissue,  the 
healthy  stroma  being  left  in  all  its  integrity." 

Disadvantages  of  the  Method. — These  are:  the  length  of 
time  necessary  for  a  cure,  the  frequent  occurrence  of 
dermatitis,  the  uncertainty  as  to  the  final  result,  the  fact 
that  a  few  cases  are  actually  made  worse,  that  recurrence 
has  been  frequently  noted,  and,  above  all,  that  the  case 
may  pass  out  of  the  operable  stage  while  awaiting  the 
action  of  the  rays. 

Some  of  these  drawbacks  are  common  to  all  methods, 
others  are  of  slight  importance,  while  the  gravest  are 
chargeable  not  to  the  method,  but  to  its  faulty  application. 

The  Advantages  of  the  Method,  on  the  other  hand,  are 
many  and  unquestionable: 

1.  The  proportion  of  cures,  in  properly  selected  cases ,  is 
as  great  or  greater  than  that  yielded  by  any  other  method. 

2.  Recurrence  is  rarer  than  by  other  methods,  and,  even 
when  it  does  occur,  ordinarily  yields  to  a  second  course  of 
treatment. 

3.  In  recurrence,  after  ablation,  the  method  gives  better 
results  than  does  surgery. 

4.  The  resulting  scar  is  far  less  disfiguring  than  that 
yielded  by  the  knife,  cautery,  or  escharotic  pastes. 

5.  Reparation  about  the  natural  orifices,  the  nose,  the 
ears,  and  eyebrows,  is  effected  with  the  least  retraction  and 
deformity  possible. 

6.  Timid  patients  are  saved  from  the  dread  of  the  knife. 

7.  The  method  is  painless,  and  usually  relieves  p;iin, 
when  present,  as  well  as  odor. 

8.  The  patient  need  not  abandon  his  occupation  during 
treatment. 


PAGET'S  DISEASE  OF  THE  NIPPLE  357 

9.  Where  the  method  fails,  recourse  may  still  be  had  to 
surgery. 

Phototherapy. — This  method  has  yielded  some  good 
results,  especially,  according  to  Finsen  and  Bie,  in  super- 
ficial and  well-demarcated  cases.  Average  cases,  according 
to  them,  require  about  thirty  exposures  of  one  hour  each. 
Forchhammer  reports  24  cases  with  11  cures.  Sjogren 
had  10  cases  and  5  cures.  Morris  and  Dore,  27  cases 
with  favorable  results  in  12.  Results  on  the  whole  are  far 
inferior  to  those  obtained  by  radiotherapy. 

Radium. — Cures  have  been  reported  by  Exner,  Scholtz, 
Holzknecht,  Abbe,  F.  H.  Williams,  Maclntyre,  Goldberg, 
London,  Hartigan,  and  Mackenzie  Davidson,  in  cases 
which  had  resisted  all  other  treatment,  including  z-rays. 
The  action  of  radium,  while  resembling  that  of  the  axrays, 
is  much  slighter,  more  limited,  and  less  certain.  On  the 
whole  it  has  so  far  proved  a  failure. 

Static  Electricity. — Skinner  obtained  good  results  in 
superficial  epithelioma,  which  had  broken  down  and  was 
making  no  progress,  by  brush  discharges  from  the  anode 
of  the  static  machine,  employed  on  alternate  days  with 
the  ar-rays. 


PAGET'S  DISEASE  OF  THE  NIPPLE. 

Description. — Paget's  disease  of  the  nipple  has  also  been 
called  malignant  papillary  dermatitis.  The  disease  almost 
always  commences  on  the  nipple,  though  it  may  occur 
elsewhere.  Women  in  the  middle  period  of  life,  or  beyond, 
are  the  common  victims  of  the  malady.  As  usually  seen 
by  the  surgeon,  the  nipple  and  areola  present  a  red,  raw, 
granular  surface,  as  though  the  epidermis  had  been  com- 
pletely removed.  The  edge  of  the  affected  area  is  sharply 
defined  and  abrupt,  and  if  the  disease  has  persisted  for 
some  time  there  is  marked  infiltration  of  the  involved 
tissues.  From  the  surface  there  is  constantly  exuding  a 
clear,  viscid  matter.  In  many  of  the  original  cases  reported 


358  NEW  GROWTHS 

by  Paget,  deep  involvement  occurred  in  two  or  three  years, 
but  in  other  cases  the  malady  has  run  a  course  of  ten  to 
twenty  years.  The  subjective  symptoms  are  tingling  and 
burning. 

The  cases  which  Thin  examined  all  showed  a  cancerous 
nature,  but  they  were  not  in  the  earliest  stages. 

Diagnosis. — Eczema  of  the  nipple  is  the  disease  with 
which  this  affection  is  most  likely  to  be  confounded,  in  its 
early  stages;  but  afterward,  when  the  cancerous  symp- 
toms are  predominant,  the  diagnosis  is  much  simplified. 
M'Call  Anderson  offers  the  following  points:  Paget's  dis- 
ease of  the  nipple  occurs  mainly  after  the  grand  climac- 
teric; eczema  of  the  nipple  and  areola  makes  its  appear- 
ance earlier,  particularly  during  lactation;  and  also  in 
scabies.  In  Paget's  disease  the  affected  surface  is  of  a 
brilliant  red,  and  raw  and  granular  looking  after  removal 
of  crusts;  in  eczema  the  surface  is  not  so  red  and  raw 
looking,  and  not  granular,  but  often  punctated.  In  Paget's 
disease  there  is  superficial  induration ;  in  eczema  the  tissues 
are  soft.  The  edge  of  the  eruption  in  Paget's  Disease  is 
abrupt  and  often  elevated ;  in  eczema  not  apt  to  be  sharply 
defined,  and  not  elevated.  Moreover,  Liveing  points  out 
that  Paget's  disease  is  unsymmetrical.  Finally,  retraction 
of  the  nipple,  lancinating  pains,  induration  of  the  breast, 
and  involvement  of  the  glands  put  the  diagnosis  beyond 
question. 

Prognosis. — The  disease  may  exist  many  years  without 
determining  any  deterioration  of  the  general  health,  but 
unless  removed  it  will  ultimately  prove  fatal.  $  If  the 
breast  is  amputated  early,  the  prognosis  is  more  favorable. 

Treatment. — In  the  earlier  stages,  as  it  is  often  extremely 
difficult  to  determine  the  true  nature  of  Paget's  disease, 
the  affected  region  should  be  treated  with  soothing  salves, 
such  as  would  be  used  in  eczema.  Under  no  circum- 
stances should  irritants  or  mild  caustics  be  used,  since 
they  simply  aggravate  the  condition.  As  soon  as  the  true 
nature  of  the  malady  is  made  out,  the  breast  should  be 
entirely  removed. 


FRAMBESIA  359 

Three  cures  so  far  have  been  reported,  but  most  observers 
have  failed,  in  the  x-ray  treatment  of  this  disease.  A  case 
treated  for  some  months  by  one  of  us  improved  for  a  time, 
but  signs  of  deeper  involvement  later  caused  him  to  desist. 
Hartzell,  employing  this  agent,  achieved  success  in  one 
case  after  two  years'  treatment.  He  believes  that  it  will  cure 
when  ducts  and  glands  are  intact. 


FRAMBESIA. 

Description. — Frambesia,  or  yaws,  is  a  disease  hardly 
ever  found  outside  the  tropics.  The  malady  usually  at- 
tacks the  negro  race,  whites  being  generally  exempt. 

There  is  an  incubation  period  followed  by  two  or  three 
well-defined  stages.  There  is  an  initial  papule  or  ulcera- 
tion,  and,  after  a  variable  period  of  fever  and  general 
disturbance,  an  eruption  of  minute  papules  makes  its 
appearance.  Some  of  these  lesions  go  on  to  form  conical 
papules,  from  which  are  developed  the  characteristic 
"  yaws,"  which  consist  of  a  mass  of  red  granulation  tissue 
covered  with  a  thin,  acid  secretion,  the  lesion  somewhat 
resembling  a  raspberry. 

The  number  of  the  lesions  varies  from  one  or  two  to 
hundreds.  The  so-called  tertiary  lesions,  gumma-like  infil- 
trations, ulcerations  of  the  pharynx  and  nares,  chronic 
periostitis,  etc.,  are  relatively  rare. 

Frambesia  is  contagious,  being  inoculable,  flies  some- 
times acting  as  the  carriers  of  contagion.  The  malady  is 
due  to  a  specific  virus,  though  no  microorganism  has  yet 
been  proved  to  be  the  cause  of  the  disease.  Children  are 
more  frequently  attacked  than  adults,  and  the  disorder  is 
rare  after  the  thirty-fifth  year. 

Treatment. — The  disease  is  rarely  fatal  if  properly 
treated,  and  it  is  often  noticeable  that,  though  the  lesions 
are  severe,  there  is  little  disturbance  of  the  general  health. 
Tonics  and  a  nutritious  diet,  in  conjunction  with  clean- 
liness, are  of  prime  importance.  Sea-bathing  seems  to  be 


360  NEW  GROWTHS 

especially  benefical.  Many  authorities  are  in  favor  of  the 
administration  of  mercury  as  a  curative  agent,  but  all  agree 
that  it  is  to  be  used  with  caution.  The  iodides  have  been 
advised,  also  thyroid  extract  and  the  erysipelas  toxins. 
The  various  ulcers  and  sores  which  may  form  are  to  be 
treated  by  washing  with  antiseptic  lotions  and  dressing 
with  iodoform  or  similar  preparations. 


FURUNCULUS  ORIENT ALIS. 

Description. — A  chronic  disease  occurring  in  certain 
localities  of  the  Orient,  also  known  as  Biskra  button, 
Delhi  boil,  and  Aleppo  evil,  etc.,  presents  painful,  ulcer- 
ating nodosities  of  exposed  parts,  leaving  scars. 

Itching  at  an  exposed  point  is  soon  followed  by  a  spot 
looking  like  a  mosquito-bite,  from  the  centre  of  which 
little  bloodvessels  radiate.  The  spot  enlarges,  scales  off, 
becomes  smooth  and  flat,  and  spreads  by  little  ridges 
of  smooth  skin,  which,  like  the  central  growth,  pit  on 
pressure. 

At  this  stage,  the  surface  is  studded  with  yellow  points 
apparently  corresponding  to  the  follicles.  The  centre  of 
the  tumor  discharges  and  scabs  over.  Ulceration  pro- 
ceeds under  the  scab,  which  is  surrounded  by  a  red,  flabby, 
irregular  zone,  presenting  papules  and  fungoid  granulations. 
Healing  progresses  from  the  centre  out,  the  cicatrix  being 
completed  in  a  few  months  or  a  year.  One  attack  usually 
confers  immunity. 

Diagnosis. — Oriental  boil  need  not  be  looked  for  in  this 
country.  It  resembles  both  syphilis  and  lupus. 

Treatment. — Altounyan  paints  the  surface  with  tincture 
of  iodine.  Fleming  used  early  cauterization  with  nitric  acid 
or  potassa  fusa.  The  Finsen  light  was  used  successfully 
in  one  case.  Crocker  suggests  the  x-rays. 


NEUROSES. 

HYPERESTHESIA. 

Description. — An  exalted  sensibility  of  the  skin,  unat- 
tended by  objective  structural  alterations,  is  of  frequent 
occurrence  in  various  functional  or  organic  diseases  of  the 
nervous  system.  It  is  especially  prone  to  occur  in  the 
hysterical  state.  At  times  it  is  apparently  idiopathic. 
There  are  some  persons  in  whom  a  cold  bath  produces  the 
most  violent  sensations  of  pain  and  burning,  even  without 
any  apparent  alterations  in  the  color  of  the  skin. 

DERMATALGIA. 

Description. — -The  skin  is  at  times  the  seat  of  a  more  or 
less  superficial  pain  of  a  rheumatic  or  neuralgic  char- 
acter, which  may  be  associated  with  marked  hyperesthesia, 
although  not  always.  Both  the  character  and  degree  of 
pain  vary  considerably,  and  it  may  be  intermittent  in  its 
attacks  or  constantly  present.  There  are  no  visible  altera- 
tions in  the  texture  of.  the  skin.  The  disorder  may  be 
general,  but  it  is  more  apt  to  affect  local  regions,  such  as 
the  scalp,  palms,  and  soles,  the  spinal  region,  etc. 

Dermatalgia  is  rarely  idiopathic,  but  is  usually  associated 
with  some  internal  disorder,  e.  g.,  malaria,  rheumatism, 
syphilis,  or  affections  of  the  nervous  system,  and  it  is  by 
no  means  infrequent  with  uterine  affections. 

Treatment. — The  treatment  consists,  when  practicable,  of 
the  removal  of  the  cause  back  of  the  dermatalgia,  that  is, 
of  the  rheumatism,  malaria,  etc.  Locally,  various  rube- 
facients,  warmth,  galvanism,  and  even  blistering  may  be 
tried.  Menthol  in  the  strength  of  2  drachms  to  1  oz. 
of  vaselin  often  affords  temporary  relief,  and  so  does  a 
chloral-camphor  ointment. 


362  NEUROSES 


ANESTHESIA. 

Description. — Anesthetic  conditions  of  the  skin  are  mostly 
associated  with  various  disorders  of  the  nervous  system, 
central  or  peripheral.  Anesthesia  is  also  a  common  symp- 
tom in  nerve  leprosy.  The  loss  of  the  sense  of  pain  in 
syphilitics,  especially  women,  is  well  known.  A  favorite 
site  of  this  manifestation  is  the  back  of  the  hand.  Taylor 
states  that  this  analgesia  is  often  combined  with  the  absence 
of  the  sense  of  touch  and  temperature.  In  other  conditions 
a  painful  hyperesthesia  may  be  associated  with  tactile  anes- 
thesia. In  the  state  called  "painful  anesthesia"  patients 
often  experience  sharp  pain  on  the  surface  of  those  portions 
of  the  body  that  are  totally  void  of  sensation.  This  variety 
of  anesthesia,  according  to  Leloir,  is  observed  frequently 
in  facial  zona,  leprosy,  Morvan's  disease,  and  the  different 
cutaneous  trophoneuroses.  This  same  authority  points 
out  that  anesthesia  is  usually  not  present  in  diseases  of  the 
skin  of  non-nervous  origin/but  it  is  the  rule  to  find  it,  more 
or  less  pronounced,  in  all  dermatoneuroses. 

Treatment. — The  treatment  is,  for  most  cases,  the  treat- 
ment of  the  causative  condition.  The  high-frequency  cur- 
rent would,  perhaps,  be  useful  where  local  measures  are 
required. 

PRURITUS.1 

Description. — Pruritus  is  a  functional  affection  of  the 
skin  in  which  the  subjective  sensation  of  itching,  or  some 
modification  thereof,  is  the  only  direct  symptom,  any  sec- 
ondary changes  or  structural  alterations  that  may  occur 
being  the  result  of  traumatism. 

In  this  sense,  pruritus  is  an  idiopathic  disease  and 
differs  from  the  pruritus  or  itching  that  attends  eczema, 
scabies,  etc. 

1  See  admirable  discussion  of  this  subject  by  E.  B.  Bronson,  in 
Medical  Record,  October  18,  1890,  and  in  Morrow's  System  of  Der- 
matology, p.  725. 


PRURITUS  363 

The  symptoms  experienced  by  persons  suffering  from 
pruritus  are  very  various.  Sometimes  there  is  only  slight 
itching  of  an  intermittent  character,  or  the  distress  may 
be  almost  continuous  and  of  so  furious  a  nature  as  to  be 
uncontrollable.  On  the  other  hand,  itching  in  the  ordinary 
sense  of  the  term  may  be  absent,  and  the  patient  will  com- 
plain of  sensations  of  crawling  or  creeping,  as  if  insects 
were  present  on  the  skin,  or  of  burning,  tingling,  or  some 
modification  of  these,  or  of  all  combined;  in  fact  the  con- 
dition of  perverted  cutaneous  innervation  which  constitutes 
the  disorder,  will  give  rise  to  an  endless  variety  of  feelings 
impossible  to  catalogue  or  describe.  In  nearly  all  instances 
the  pruritus  is  worse  at  night,  and  thus,  tormented  by  day 
and  robbed  of  sleep  by  night,  the  state  of  the  sufferer  is 
rendered  pitiable  to  the  extreme,  and  in  aggravated  cases 
suicide  or  insanity  may  be  the  final  outcome.  According 
to  the  degree  of  itching  will  be  the  effects  upon  the  skin  of 
the  attempts  to  relieve  it.  At  times  the  secondary  changes 
will  be  marked,  and  the  integument  will  exhibit  scratch- 
marks,  papules,  pustules,  and  varying  depths  of  pigmen- 
tation. Again,  there  will  be  little  or  no  evidence  of  trauma- 
tism,  the  suffering  often  being  more  mental  than  physical. 
Indeed,  complaint  of  abnormal  sensations  in  the  skin  is 
frequently  a  sign  of  mental  aberration,  and  every  physician 
will  recall  patients  with  the  fixed  and  ineradicable  hallu- 
cination that  they  were  the  hosts  of  ants,  bugs,  and  all 
manner  of  creeping,  crawling,  and  biting  creatures.  The 
desire  to  scratch  is  irresistible,  and  patients  in  efforts  to 
gratify  the  passion  will  not  only  use  the  nails  until  they  are 
worn  away,  but  will  employ  flesh  brushes,  sticks,  corn-cobs, 
and  even  sand-paper.  After  a  paroxysm  of  scratching  the 
nervous  exhaustion  is  often  extreme. 

Since  the  whole  of  the  cutaneous  surface  may  be  more 
or  less  involved  in  the  pruritus,  and  at  other  times  the  dis- 
order is  strictly  confined  to  certain  defined  regions,  it  is 
customary  to  speak  of  the  disease  as  being  universal  or 
local. 

Pruritus  Universalis. — It  is  rare  for  pruritus  to  be  abso- 
lutely general;  it  is  more  apt  to  be  limited  to  certain 


364  NEUROSES 

rather  extensive  tracts,  or  in  turn  to  invade  one  part  after 
another.  The  general  form  may  occur  at  any  time  of  life 
and  be  dependent  on  a  great  variety  of  etiological  factors, 
but  most  cases  of  this  sort  are  to  be  found  in  the  aged,  in 
whom  the  affection  is  most  severe  and  intractable. 

Pruritus  Localis. — In  the  local  varieties  of  the  disease 
certain  special  regions  of  the  body  may  be  the  only  parts 
attacked,  the  disorder  being  localized  and  showing  no  ten- 
dency to  extend.  In  this  way  the  itching  may  be  present  on 
the  face,  the  eyelids,  between  the  fingers,  over  the  backs  of 
the  hands,  or  affecting  certain  fairly  outlined  areas.  Pruri- 
tus ani  is,  perhaps,  the  most  common  of  the  localized  forms. 
It  is  met  with  at  all  times  of  life,  and  in  both  sexes.  The 
itching  is  generally  very  severe,  particularly  at  night,  and 
the  scratching  produces  excoriations,  artificial  eczema, 
cicatrices,  and  dense  infiltration.  The  itching  sensations 
may  be  external,  or  extend  to  the  mucous  membrane. 
Pruritus  scroti  is  often  associated  with  that  about  the  anal 
region,  extending  along  the  raphe  of  the  perineum.  Here, 
as  elsewhere,  all  grades  of  itching  may  be  present,  as  well 
as  the  degree  of  secondary  change  induced  by  the  scratch- 
ing. In  bad  cases  the  suffering  is  intense.  Pruritus  vulvae 
or  pudendorum  is  frequent,  affecting  the  labia  and  clitoris, 
and  producing  eczema,  vaginitis,  great  heat  and  swelling 
of  the  parts,  and  sometimes  inducing  nymphomania. 

Pruritus  Hiemalis. — This  is  that  form  of  itching  of  the 
skin  to  which  Duhring  first  called  attention,  and  which  is 
influenced  in  its  development  by  atmospherical  conditions. 
The  pruritus  is  usually  established  with  the  first  change 
of  the  weather  in  the  autumn,  and  with  varying  degree,  of 
intensity  dependent  upon  the  variations  in  the  atmosphere, 
will  persist  until  the  warm  season  has  begun.  As  in  all 
other  forms  of  the  disease,  the  itching  is  worse  at  night.  The 
pruritus  is  rarely,  if  ever,  universal,  being  confined  mostly 
to  the  inner  surface  of  the  thighs  and  lower  limbs.  Duhr- 
ing says  that  it  occurs  in  both  sexes  equally,  at  all  ages  after 
puberty,  and  is  uninfluenced  by  the  state  of  the  general 
health.  Once  established,  the  affection  is  apt  to  recur 


PRURITUS  305 

every  winter.  We  have  patients  under  our  care  in  whom 
the  pruritus  has  thus  reappeared  at  the  first  spell  of  cold 
weather  for  many  years.  On  the  other  hand,  for  some 
unknown  reason,  this  susceptibility  may  diminish  or  may 
altogether  disappear. 

Stelwagon  has  described  a  form  of  itching  which  he  calls 
bath  pruritus.  In  these  cases  various  degrees  of  burning 
and  itching  immediately  follows  bathing.  In  our  experi- 
ence it  is  relatively  common. 

In  order  to  treat  pruritus  successfully  its  etiology  must 
be  well  understood.  Pruritus  in  the  aged  is  usually  due 
to  senile  degeneration  of  the  skin.  Among  the  causes  of 
pruritus,  as  commonly  encountered,  may  be  mentioned 
functional  and  organic  diseases  of  the  liver,  dyspepsia, 
Bright's  disease,  constipation,  etc.  Certain  drugs  and 
articles  of  diet  also  induce  pruritus;  among  the  former 
opium  and  its  preparations  are  to  be  especially  mentioned, 
and  among  the  latter  oatmeal  and  the  inordinate  drinking 
of  tea. 

A  long  list  of  sexual  derangements  may  also  be  referred 
to,  and  the  pruritus  of  pregnancy  is  a  matter  of  common 
observation.  Various  disorders  of  the  nervous  system  are 
complicated  by  itching  of  the  skin,  and  the  influence  of 
abnormal  mental  states  is  well  recognized. 

Pruritus  ani  in  many  cases  is  associated  with  hemor- 
rhoids, and  in  children  the  same  difficulty,  as  well  as 
vaginal  pruritus,  is  due  to  the  presence  of  intestinal  worms. 
Pruritus  vulva?  is  often  caused  by  uterine  disease,  leucor- 
rhea,  and  vaginismus,  although  it  may  be  apparently 
idiopathic.  The  possibility  that  an  intractable  vaginal 
pruritus  may  be  one  of  the  earliest  symptoms  of  uterine 
cancer  should  always  be  borne  in  mind.  It  is  also  well  in 
persistent  local  pruritus  to  examine  the  urine  for  sugar. 

Diagnosis. — It  is  always  a  matter  of  much  importance 
to  know  whether  pruritus  is  primary,  so  to  speak,  or 
whether  it  is  secondary  to  certain  other  affections.  For 
example,  excessive  itching  of  the  skin  is  associated  with 
ec/ema,  scabies,  pediculosis,  urticaria,  and  a  number  of 


366  NEUROSES 

other  disorders;  but,  all  of  these  exhibit  well-marked 
symptoms,  whereas  in  pruritus,  aside  from  alterations  in 
the  skin  due  to  scratching,  the  itching  is  the  only  direct 
manifestation  of  the  disorder.  In  pediculosis,  the  character 
of  the  scratch  marks,  their  location  about  the  neck  and 
loins;  in  scabies,  the  furrows,  the  multiform  lesions,  and 
their  characteristic  preference  for  the  sides  of  the  fingers, 
buttocks,  genitals,  and  breasts  of  women;  in  eczema,  the 
preexisting  eruption;  and  in  urticaria,  the  evanescent 
wheals  should  all  be  considered  in  establishing  diagnosis. 

In  the  local  forms  of  pruritus  it  is  necessary  to  ascertain 
the  causes  of  the  itching,  whether  hemorrhoids,  worms, 
pediculi,  etc. ;  in  fact,  in  all  forms  of  the  disease  the  general 
is  more  important  than  the  local  diagnosis. 

Prognosis. — It  may  be  said  that  generalized  pruritus 
admits  of  a  better  prognosis  than  the  local  forms;  however, 
senile  pruritus  and  the  pruritus  dependent  upon  incurable 
organic  diseases  offer  notable  exceptions  to  this  rule.  All 
the  local  varieties  of  the  disorder  are  more  or  less  intract- 
able, and  the  physician  should  be  guarded  in  the  expression 
of  his  opinion  as  to  their  curability.  Putting  aside,  how- 
ever, cases  obviously  the  result  of  irremovable  causes,  e.  g., 
genital  pruritus  due  to  pelvic  tumors,  general  pruritus  from 
cancer  of  the  liver,  etc.,  it  will  be  found  that  a  satisfactory 
outcome  may  often  be  obtained  if  the  patient  is  willing  to 
follow  implicitly  the  instructions  given  him. 

Treatment. — The  general  treatment  of  pruritus  consists, 
for  the  most  part,  in  the  use  of  measures  for  the  cure  or 
relief  of  exciting  or  complicating  disorders.  In  this  way 
every  part  of  the  system  should  be  interrogated,  and  pains 
should  be  taken  to  correct  any  organic  or  functional  dis- 
order that  may  be  present.  Particular  attention  should 
be  directed  to  the  state  of  the  stomach,  bowels,  kidneys,  and 
liver.  The  existence  of  a  pre-icteric  pruritus  emphasizes 
the  necessity  for  attention  to  the  condition  of  the  liver  and 
biliary  passages.  The  diet  is  often  at  fault,  or  sometimes 
it  will  be  found  that  certain  articles,  like  oatmeal  or  tea,  are 
responsible  for  the  itching.  Tobacco  undoubtedly  keeps 


PRURITUS  367 

up  and  aggravates  anal  pruritus.  There  are  several 
remedies  that,  given  internally,  have  some  reputation  as 
antipruritics.  Among  those  may  be  mentioned  carbolic 
acid  (1  or  2  minims  three  times  a  day),  wine  of  antimony 
(5  to  7  drops  after  meals),  tincture  of  cannabis  indica  (10 
minims  gradually  increased  to  30,  three  times  a  day), 
quinine  (10  gr.  at  bedtime),  tincture  of  gelsemium  (10 
minims  every  half-hour  until  1  drachm  has  been  given  or 
toxic  effects  are  experienced),  and  pilocarpine  (f  gr.  hypo- 
dermically).  Salicylate  of  sodium  and  salicylate  of  strontium 
often  act  well.  Valerianate  of  ammonium,  the  bromides, 
chloral,  and  other  hypnotics  are  useful  at  times.  De 
Wannemacker  has  given  salophen  in  doses  of  60  to  75  gr. 
a  day  with  encouraging  results.  Savill  advises  calcium 
chloride  both  in  primary  and  secondary  forms  of  pruritus. 
It  may  be  given  well  diluted  in  20,  30  or  even  40-gr.  doses, 
three  times  a  day.  The  diet  should  be  regulated,  the 
bowels  kept  open,  and  the  remedy  persevered  with  for 
several  weeks  after  a  cure  has  been  effected. 

The  local  treatment  of  pruritus  comprises  a  vast  array 
of  remedies.  For  general  pruritus  may  be  employed  baths, 
electricity,  lotions,  and  ointments. 

A  warm  bath  composed  of  8  oz.  of  bicarbonate  of  sodium, 
to  which  has  been  added  bran  liquor  made  by  infusing 
several  pounds  of  bran,  is  soothing  and  agreeable.  After 
the  skin  has  been  gently  dried,  it  may  be  anointed  with 
carbolated  vaselin,  5  to  10  minims  to  1  oz.  Mercurial 
and  sulphur  baths  may  also  be  tried.  At  the  Hopital 
Saint-Louis,  Paris,  pruritus  senilis  is  treated  by  hot  starch 
baths  at  night,  followed  by  sponging  with  a  mixture  of 
1  part  of  carbolic  acid  to  50  parts  of  aromatic  vinegar, 
stirred  into  a  bowl  of  hot  water.  Afterward  a  powder  of  1 
part  of  salicylate  of  bismuth  (or  salicylic  acid)  to  9  parts  of 
starch  is  gently  rubbed  in  with  the  hand. 

We  have  made  much  use  of  electricity  in  its  various 
modes  of  application,  namely,  galvanism,  general  faradi- 
zation, etc.,  without  much  more  than  temporary  results; 
however,  the  mental  effect  is  good,  a  fact  which  explains  a 


368  NEUROSES 

good  part  of  electrical  therapeutics.  It  is  but  just  to  add, 
however,  that  Polotebnoff  claims  good  results  with  brush 
or  pad  electrodes  (faradization).  Others  praise  static 
insulation  and  static  applications  to  the  spine. 

Powders  of  many  sorts  have  been  recommended. 

Anderson's  antipruritic  powder  is  well  known: 

1$ — Pulv.  amyli 3vj 

Zinci  oxidi 3jss 

Pulv.  camphorae oss — M. 

Leloir  gives  a  list  of  powders  that  he  has  found  useful : 

1$ — Acidi  salicylic! gr.  xv 

Zinci  oxidi oj 

Pulv.  amyli        .      .      .      .      .      .      .      .      .    3ij — M. 

1} — Boracis oss 

Talci ojjss 

Zinci  oxidi 3  j 

Amyli  oryzse 3ij — M. 

Lotions  of  various  kinds  are  much  recommended, 
composed  of  carbolic  acid,  thymol,  liq.  carbonis  detergens, 
liq.  picis  alkalinus,  benzoic  acid,  etc. 

Carbolic  acid  is  probably  the  most  valuable  of  all  the 
remedies  used  in  pruritus,  and  employed  in  the  form  of  a 
spray,  with  a  hand-ball  atomizer,  after  the  manner  origi- 
nally suggested  by  one  of  us,1  its  efficacy  is  considerably 
increased,  besides  being  more  cleanly  and  more  conveni- 
ently applied.  We  generally  prescribe  the  following  lotion: 

1^ — Acidi  carbolici oiij-oiv 

Glycerin! 3j 

Aquae '.      q.  s.  ad  Oj — M. 

S. — Use  as  a  spray. 

To  increase  the  antipruritic  effect  it  is  a  good  plan  to 
add  5  to  10  minims  of  the  oil  of  peppermint  to  each 
atomizerful  of  the  lotion.  This  must  be  well  shaken  just 
before  being  used.  In  cold  weather  the  atomizer  may  be 

1  Hardaway,  Journal  of  Cutaneous  and  Venereal  Diseases,  April, 
iss-,. 


PRURITUS  369 

placed  in  a  vessel  of  hot  water.  Any  substance  that  is 
"sprayable"  may  be  thus  utilized,  such  as  liq.  carbonis 
detergens,  etc.  The  spray  may  be  used  as  often  as  desired. 
Among  other  valuable  lotions  may  be  mentioned  the 
following : 

1$ — Fol.  belladonnae, 

Fol.  hyoscyami aa  oij 

Fol.  aconiti 3ss 

Acidi  acetici 3j — M. 

S. — To  be  diluted  with  water,  1  drachm  to  1  oz.  Taylor. 

1^— Thymolis .      .      .  3ij 

Liq.  potassae 3j 

Glycerini Siij 

Aquae Sviij — M. 

S. — Local  use.  Crocker. 

]$ — Acidi  carbolici 3ij 

Potass,  causticae 3j 

Aquae §iv — M. 

S. — Local  use.    To  be  diluted  if  too  irritating.  Bulkley. 

3$ — Mentholis gr.  ij-x 

Aquae 3j — M. 

S. — Local  use. 

T$ — Boracis oij 

Glycerini 5j 

Spt.  camphorae 5ss 

Aquae  rosse Svjss — M. 

S. — Local  use.  Duhring. 

1$ — Liq.  carbonis  detergentis 3j 

Zinci  oxidi 5ss 

Pulv.  calaminae  praep 9jv 

Glycerini 3j 

Liq.  calcis 3vij — M. 

S. — Shake.    Apply  freely. 

This  is  a  very  satisfactory  combination  in  many  cases. 
Carbolic  acid  may  be  substituted  for  the  tar  preparation  in 
the  same  proportion.     Menthol,  combined  in  the  following 
way,  will  be  successful  in  many  cases : 
24 


370  NEUROSES 

I$— Mentholis 3ij 

Alcoholis q.  s. 

Acidi  carbolici n\xx 

Lotionis  zinci  oxidi  comp 3iv — M. 

Bronson's  lotion  is  very  valuable: 

^ — Acidi  carbolici 3j-3ij 

Liq.  potassae      . 3j 

Olei  Hni 5j— M. 

A  number  of  years  ago  one  of  us1  called  attention  to  the 
value  of  the  local  application  of  cider  vinegar,  followed  by 
citrine  ointment — a  plan  of  treatment  quoted  by  Watson  in 
his  classical  work. 

Bowling  advises  that  the  parts  be  sponged  twice  a  day 
with  the  vinegar,  and  that  the  citrine  ointment  should  be 
smeared  over  the  surface  after  the  former  has  dried.  Too 
large  a  region  should  not  be  subjected  to  this  treatment  at 
one  time. 

Ointments  of  sulphur,  tar,  or  of  the  two  combined  (1 
drachm  of  each  to  1  oz.)  are  valuable.  Bulkley's  chloral 
and  camphor  salve  is  also  of  service : 

I$— Chloralis, 

Camphorae aa  3ss-3j 

Ung.  aq.  rosse 5j — M. 

S. — Local  use. 

The  use  of  a  hot  bath  with  green  soap,  followed  by  sul- 
phur salve  inunctions,  is  sometimes  efficient,  even  where 
there  is  no  suspicion  of  scabies  in  the  case.  Ointments, 
as  a  rule,  are  of  more  benefit  in  local  forms  of  pruritus. 

Good  results  are  often  obtained  from  menthol  in  salve 
form: 

1$ — Mentholis oij 

Olei  amygdalae  dulcis oij 

Lanolim 3vj — M. 

We  have  faithfully  tried  bromokoll  in  10  per  cent,  and 
20  per  cent,  salves  and  pastes,  but  we  have  by  no  means 
succeeded  in  getting  the  benefit  claimed  for  it  by  German 
writers. 

1  Hardaway,  St.  Louis  Clinical  Record,  December,  1874. 


PRURITUS  371 

The  best  prescription  for  the  sufferer  from  winter  itch 
is  a  sojourn  in  the  South  during  the  cold  weather.  We  have 
relieved  at  least  one  obstinate  case  by  directing  that  heavy 
woolen  drawers  be  worn  over  nainsook,  although  change 
in  the  underclothing  usually  remains  without  much  effect. 
The  usual  antipruritic  salves  and  lotions  may  be  tried  as 
in  pruritus  generally.  Menthol  and  carbolic  acid  used  in 
connection  with  the  compound  zinc  lotion  generally  give 
temporary  relief.  If  the  skin  is  naturally  harsh,  the  men- 
thol and  carbolic  acid  may  be  prescribed  in  a  soft  ointment, 
or  salicylic  acid  may  be  ordered  in  the  strength  of  10  gr. 
to  1  oz.  in  a  salve  compound  of  equal  parts  of  lanolin, 
vaselin,  and  benzoated  lard  (Stel wagon).  It  is  a  fact  that 
with  many  persons  this  peculiar  susceptibility  disappears 
in  the  course  of  time. 

In  our  experience,  but  little  can  be  accomplished  in  the 
treatment  of  bath  pruritus.  Occasionally  persons  who  can- 
not take  a  cold  bath  without  suffering  experience  but  little 
discomfort  when  hot  water  is  used,  and  others  can  indulge 
in  a  Turkish  bath  with  impunity.  Stelwagon  recommends 
salt  baths  in  some  cases,  and  in  others  alkaline  baths,  and 
following  the  bath  the  application  to  the  skin  of  a  bland 
dusting  powder,  or,  if  that  is  ineffectual,  the  inunction  of 
some  soft,  creamy  salve  or  a  glycerin  lotion.  A  small 
quantity  of  carbolic  acid  or  thymol  may  be  added.  This 
same  authority  advises  proper  constitutional  measures  if 
required,  and  states  that  in  lithemic  subjects  small  doses  of 
salicylate  of  sodium  are  of  value.  Arsenic  has  also  been 
suggested. 

In  the  treatment  of  the  strictly  local  forms  of  pruritus 
it  is  also  necessary  to  seek  diligently  for  the  exciting  or 
complicating  causes  of  the  disorder,  and,  if  possible, 
remove  them.  The  local  remedies  are  very  numerous,  but, 
in  addition  to  those  already  mentioned,  we  shall  give  only 
such  as  have  proved  useful  in  our  own  hands,  or  are  recom- 
mended by  competent  authorities. 

Pruritus  Scroti. — In  most  cases  a  well-fitting  suspen- 
sory bandage  is  of  decided  benefit.  Sometimes,  when  the 


372  NEUROSES 

pruritus  is  accompanied  by  considerable  sweating,  a  dust- 
ing powder  of  thymol  and  oleate  of  zinc  (!$ — Thymol.,  gr.  j ; 
pulv.  zinci  oleatis,  5j — M.)  is  demanded.  Bulkley's  method 
with  tar  salve  and  hot  water  (see  Eczema  of  the  Scrotum) 
often  does  equally  good  service  in  pruritus  of  this  region. 
The  same  author's  camphor  and  chloral  mixture  may  also 
be  tried.  The  mercurial  preparations  are  to  be  highly 
recommended,  especially  the  white  precipitate  (1$ — Hydrar- 
gyri  ammoniati,  gr.  xx;  adipis  benzoati,  §  j — M.).  Calomel 
in  the  strength  of  \  to  1  drachm  to  1  oz.  may  be  prescribed 
in  place  of  the  ammoniated  mercury.  The  vinegar  appli- 
cations followed  by  citrine  ointment  are  often  curative. 
The  yellow  and  black  washes  are  occasionally  prescribed. 
Liveing's  perchloride  of  mercury  lotion  (1$ — Hydrargyri 
bichloridi,  gr.  ij-iv;  acidi  hydrocyanic!  diluti,  3JJ  emuls. 
amygdalae,  5vnj — M.)  may  be  employed  when  the  skin  is 
unbroken.  Carbolic  acid  lotions  and  ointments  are  as 
valuable  here  as  elsewhere.  Pencillings  with  the  nitrate  of 
silver  solution  (1$ — Argenti  nitratis,  gr.  xvj ;  spiritus  setheris 
nitrosi,  §j — M.)  are  sometimes  surprisingly  beneficial. 
In  intractable  cases  Vidal  makes  multiple  scarifications 
with  the  scarificator  of  B.  Squire. 

Pruritus  Ani. — Carbolic  acid,  15  to  40  gr.  to  1  oz.  of  oil 
of  sweet  almonds,  is  highly  spoken  of  by  Duhring.  Men- 
thol may  be  added  to  the  carbolic  acid  in  this  prescription, 
or  the  carbolic  acid  and  menthol  may  be  prescribed  in  the 
form  of  a  paste.  (See  additional  prescriptions.) 

The  various  tar  and  mercurial  preparations,  and  particu- 
larly the  latter,  at  one  time  or  another  give  relief.  A 
bismuth  and  morphine  salve  (]$ — Bismuth!  nitratis,  3JJ 
morphinse  hydrochloratis,  gr.  ij;  ung.  aquee  rosse,  §j — M.) 
is  said  by  Liveing  to  be  especially  valuable.  Balsam  of 
Peru  of  the  strength  of  1^  drachms  to  1  oz.  of  simple  oint- 
ment is  occasionally  helpful.  The  compound  gall  ointment 
of  the  pharmacopoeia  has  been  much  employed,  and  is 
especially  useful  if  hemorrhoids  are  present.  Lassar's 
paste  (see  Eczema),  kept  thinly  smeared  over  the  parts 
night  and  day,  is  an  excellent  remedy.  Suppositories  of 


PRURITUS  373 

cocaine  or  belladonna  give  temporary  relief.  Pencilling 
the  part  with  the  nitrate  of  silver  solution  mentioned  above 
is  to  be  recommended,  particularly  when  cracks  and  fis- 
sures exist.  The  hot  water  and  tar  treatment  already 
referred  to  gives,  perhaps,  more  immediate  relief  than  any 
other  method  at  our  command. 

Seat-worms  will  occasionally  be  found  in  adults,  and 
oftener  in  children,  and  are  best  dealt  with  by  enemata 
of  infusion  of  quassia  chips.  Brocq  has  succeeded  with 
Vidal's  method  of  multiple  scarification  in  vulvar  and  anal 
cases  after  all  else  had  failed. 

Recourse  to  radiotherapy  would  only  be  justifiable  in 
cases  that  have  resisted  other  treatment.  Soft  rays  should 
be  used  in  mild  doses  at  long  intervals. 

We  can  add  our  testimony  as  to  its  value  in  anal  and 
vulvar  pruritus  to  that  of  Pusey. 

High-frequency  currents  are  often  very  efficient  in  gen- 
eral pruritus. 

Pruritus  Vulvse. — The  first  thing  to  do  for  the  relief  of 
this  condition  is  to  seek  for  its  cause  and,  if  possible,  remove 
it.  The  causes  have  been  found,  in  our  experience,  in 
about  the  following  order  of  frequency:  (1)  neuropathy; 
(2)  leucorrhea;  (3)  glycosuria;  (4)  seat-worms  (the  latter 
more  often  in  children,  although  one  of  our  cases  was 
found  in  the  wife  of  a  physician). 

When  the  parts  are  hot  and  swollen  from  excessive 
scratching,  great  relief  may  be  obtained  by  the  use  of  very 
hot  water  followed  by  tar  ointment  and  cold  cream  (]$ — 
Ung.  picis  liq.,  5ij;  ung.  aq.  rosse,  3vj — M-)  or  the  ung. 
vaselini  plumbicum  spread  on  lint.  A  10  per  cent,  solution 
of  cocaine  will  give  temporary  relief.  Schwimmer  recom- 
mends an  ointment  of  alumina  (]$ — Alumin.  hydrat., 
5jss;  glycerini,  olei  olivae,  aa  3V5  ung-  mollis,  3X — M-)- 
Goodell  relies  on  an  infusion  of  tobacco,  of  the  strength  of 
2  drachms  of  the  leaf  to  1  pint. 

Saturated  solution  of  boric  acid  is  thought  well  of  by 
some  physicians.  Reeve  directs  that  the  parts  be  painted 
every  night  with  the  compound  tincture  of  benzoin  (B.  P.). 


374  NEUROSES 

Robinson  says  that  an  ethereal  solution  of  iodoform  in 
spray,  or  an  iodoform  ointment,  is  occasionally  useful. 
The  solution  of  silver  in  nitrous  ether  (16  gr.  to  1  oz.)  often 
does  well.  The  carbolic  acid  spray,  with  oil  of  peppermint, 
referred  to  above,  may  also  be  advised.  Routh  recom- 
mends that  1  teaspoonful  of  borax  be  put  in  1  pint 
bottle  of  hot  water,  to  which  is  added  5  drops  of  oil  of 
peppermint,  with  which,  after  thorough  shaking,  the  parts 
are  to  be  freely  mopped  with  a  soft  sponge. 

Conium  ointment  as  recommended  by  Whitla  (vide 
infra)  is  of  especial  value.  Hirst  and  Deaver  advocate 
section  of  sensory  nerves  in  incoercible  cases. 

In  all  forms  of  pruritus  about  the  genital  and  anal 
regions  scrupulous  cleanliness  is  required,  and  when  prac- 
ticable the  surfaces  should  be  kept  apart  by  the  interposi- 
tion of  lint  or  absorbent  cotton. 


ADDITIONAL  PRESCRIPTIONS. 

i — Ext.  hamamelis  fld 

Ext.  ergotae  fld 

Ext.  hydrastis  fld 

Tinct.  benzoini  comp.        .... 
Ol.  olivse  carbolat.  (5.0  carbolic  acid) 


f5ij 
f3ij 
f5j— M. 


S. — 1  to  1\  drachms  to  be  injected  into  rectum  daily.  If  peri- 
neal  skin  is  infiltrated,  paint  on  solution  nitrate  of  silver,  96  gr.  to 
1  oz.  When  parts  have  become  normal,  apply  citrine  ointment  for 
two  weeks,  then  twice  a  week  for  several  months.  Adler. 

If — Mentholis gr.  iij 

Acidi  carbolici gr.  iv 

Acidi  salicylici »M 

Zinci  oxidi 3jss 

Liq.  petrolati 3j — M. 

S. — Apply  locally.  Broc<|. 

1^ — Resorcini gr.  xv-xxx 

Sodii  chlpridi gr.  xv 

Glycerini 3ij 

Liquor,  calcis q.  s.  ad  5iv — M. 

S. — External  use.  Hartzell. 


PRURITUS  375 

IJ — Acidi  acetici        gr.  Ixxv 

Lanolini  pur ovijss 

Vaselini 3v — M. 

S. — Use  on  the  dry  pruritic  skin.  Leistikow 


1$ — Creosoti  purif n^xxx 

Cocainae  nydrochlor gr.  xij 

Ung  conii 5j — M. 

S. — External  use  in  pruritus  of  the  anus  and  female  genital  organs. 
Give  a  small  cold  water  injection  at  bedtime,  after  which  smear 
parts  with  hemlock  ointment  (plain  or  as  above),  some  of  it  being 
pushed  up  in  the  vagina  or  rectum  by  the  finger.  Whitla. 


1$ — Ung.  picis  liquidse 3vj 

Ung.  belladonna? 5iv 

Tr.  aconiti 5j 

Zinci  oxidi 5ij 

Ung.  aq.  rosae 3vj — M. 

S. — In  pruritus  of  anus  and  vulva.    To  be  used  cautiously. 

Bulkley. 

1$ — Acidi  carbolici gr.  x-xx 

Hydrarg.  chlor.  mitis gr.  xx-xxx 

Ung.  zinci  oxidi 3j — M. 

S. — In  anal  pruritus.  Schamberg. 

1$ — Mentholis gr.  xlv 

Olei  olivae, 

Lanolini          aa  5j — M. 

S. — For  external  use  in  senile  pruritus.  Eloy. 


1^ — Acidi  acetici gr.  Ixxv 

Misce  cum : 

Terra  silicia oijss 

Adde: 

Lanolinum  pur 3vjss 

Vaselinum Sijss — M. 

S. — A  paste  for  the  oily  pruritic  skin.  Leistikow. 


1} — Mentholis 3j 

Acidi  carbolici 5j 

Ol.  amygdalae  dulcis 3j 

Cerati  simplicis 3ij 

Pulv.  zinci  oxidi 3ij — M. 

S. — Local  use  in  pruritus  of  the  anal  region. 


DISEASES  OF  THE  APPENDAGES  OF 
THE  SKIN. 


DISEASES  OF  THE  SWEAT  GLANDS. 
HYPERIDROSIS. 

Description. — Hyperidrosis  is  a  functional  disorder  of  the 
sweat  glands  in  which  the  secretion  is  produced  in  excess. 
This  abnormal  condition  may  be  general  or  partial,  acute 
or  chronic;  it  may  but  slightly  exceed  the  natural  per- 
spiration, or,  on  the  other  hand,  be  given  off  in  large 
amounts.  The  general  forms  are  mostly  symptomatic, 
occurring  in  connection  with  phthisis  and  other  conditions 
of  debility,  or  in  the  course  of  various  febrile  states. 

Very  fat  people,  and  those  much  given  to  stimulants,  also 
suffer  from  general  sweating  of  the  surface.  Hyperidrosis 
affecting  one  side  of  the  body  or  one  limb  may  sometimes 
occur. 

The  local  forms  of  the  disease  are  those  that  especially 
concern  the  dermatologist.  In  most  cases  the  affection  is 
found  upon  the  palms  of  the  hands,  axillae,  the  inguinal 
region,  and  the  soles  of  the  feet.  In  these  regions,  as  else- 
where, the  amount  of  the  secretion  may  be  great  or  little. 
The  hyperidrosis  is  in  some  cases  unilateral.  When  the 
palms  or  soles  are  involved  the  parts  may  merely  feel  cold 
and  clammy,  or  else  warm  and  moist. 

Sometimes  the  secretion  appears  in  small  drops,  or  it 
may  drip  from  them  as  freely  as  if  the  members  had  been 
dipped  into  a  basin  of  water.  We  believe  this  very  free 
discharge  is  oftener  seen  on  the  palms  than  on  the  soles. 
Excessive  sweating  may  give  rise  to  intertrigo  or  eczema 
in  certain"  situations,  e.  g.,  about  the  genitals  and  between 


HYPERIDROSIS  377 

folds  of  the  skin.  Many  persons  who  sweat  profusely 
about  the  scalp  suffer  later  from  alopecia.  On  the  feet 
especially  perspiration  is  apt  to  have  a  disgusting  odor 
(bromidrosis),  and  the  skin  has  a  sodden,  macerated 
appearance. 

Persons  of  all  ages,  of  both  sexes,  the  rich  and  the  poor, 
the  cleanly  and  the  dirty  are  subject  to  this  affection.  The 
cause  or  causes  are  obscure,  but  probably  in  most  cases 
there  is  some  fault  in  the  nervous  system.  Crocker  states 
that  slight  hyperidrosis  of  the  palms  may  be  congenital 
and  occasionally  hereditary.  Buzzi  believes  that  the  exces- 
sive sweating  of  fat  persons  is  due  to  a  passive  hyperemia, 
arising  from  an  obstruction  to  the  venous  blood  caused 
by  the  pressure  of  the  subcutaneous  fat,  and  not  by  the 
increased  exertion  necessary  in  stout  people.  Cutler 
regards  hyperidrosis  as  a  functional  affection  of  the  sym- 
pathetic system.1 

There  is  no  doubt  that  flat-foot  is  often  associated  with 
hyperidrosis  pedum. 

Prognosis. — The  prognosis  should  be  guarded.  Some 
cases  recover  more  or  less  promptly,  while  others  defy  all 
treatment.  Sweating  of  the  feet  would  seem  to  be  more 
amenable  to  remedies  than  a  similar  condition  of  the 
hands. 

Treatment. — In  all  cases  it  is  well  to  treat  obvious  devia- 
tions from  health.  The  treatment  of  the  night-sweats  of 
phthisis,  etc.,  need  not  be  gone  into  here.  Often  enough 
no  special  indication  can  be  determined,  and  then  it  is 
necessary  to  try  the  effect  of  the  so-called  specifics.  Among 
these  may  be  mentioned  belladonna,  atropia,  agaricin,  and 
ergot.  In  our  experience  their  effect  is  only  temporaiy 
at  best;  besides,  in  the  case  of  belladonna  and  its  alkaloid, 
putting  the  patient  to  considerable  inconvenience.  Krahn 
prescribes  20  drops  of  tincture  of  salvia  (sage)  in  the  morn- 
ing and  20  to  40  drops  at  bedtime.  It  must  be  continued  for 
several  weeks.  Camphoric  acid  is  highly  recommended  in 

1  Journal  of  Cutaneous  and  Venereal  Diseases,  February,  1888. 


378  DISEASES  OF  THE  SWEAT  GLANDS 

various  forms  of  sweating  by  a  number  of  writers.  Crocker 
says  that  the  best  remedy  is  a  level  teaspoonful  of  precipi- 
tated sulphur,  in  milk,  twice  a  day.  If  it  prove  too  laxative 
it  may  be  combined  as  follows,  and  given  in  the  same  dose : 

1$ — Pulv.  cretse  comp 5vj 

Pulv.  cinnamomi  comp 5ij 

Sulphuris  praecipitati 3j — M. 

The  local  applications  are  numberless. 

Fox  recommends  a  1  per  cent,  solution  of  quinine  in 
alcohol;  Crocker,  a  belladonna  ointment  or  liniment; 
Rohe,  a  prescription  containing  8  gr.  of  tannin  to  4  oz.  of 
bay  rum,  followed  by  a  dusting  powder  consisting  of  starch, 
combined  with  oxide  of  zinc,  boric  acid,  or  salicylic  acid. 
We  have  found  a  solution  of  salicylic  acid  in  alcohol 
(1  drachm  to  4  oz.)  to  do  good;  also  a  saturated  solution  of 
boric  acid.  The  application  of  very  hot  water  is  tem- 
porarily beneficial. 

Unna  recommends  for  hyperidrosis  capitis  a  superfatted 
formalin  soap  and  Leistikow  a  solution  of  resorcin  and 
salicylic  acid.  The  following  prescription  is  often  useful: 

1$ — Resorcini gr.  xlviij 

Acidi  tannici, 

Chloral  hydratis aa  3jss 

Tr.  benzoin! 3ss 

Ol.  ricini 3ij 

Alcoholis q.  s.  ad  Sviij — M. 

S. — Apply  small  quantity  to  the  scalp  with  a  medicine  dropper. 

In  order  to  avoid  excessive  perspiration  of  the  axillary 
region  the  parts  should  be  kept  as  well  ventilated  as  possible, 
that  is  to  say,  rubber  pads  and  such  contrivances  should  be 
avoided  and  scrupulous  cleanliness  observed.  Formalin 
soap  is  useful  (Unna)  and  the  various  dusting  powders 
containing  small  amounts  of  salicylic  and  boric  acids  may 
be  prescribed.  Heusner's  prescription  (vide  infra)  con- 
taining balsam  of  Peru  and  formic  acid  is  valuable. 

Sweating  in  the  femoral  region  may  be  treated  on  the 
same  general  plan,  but  pastes  act  very  well  in  these  parts 
and  are  especially  useful  in  preventing  intertrigo. 


UYPERIDROSIS  379 

1$ — Acidi  salicylic! gr.  x 

Talci, 

Zinci  oxidi aa     5ij 

Vaselini 5iv — M. 

S. — Apply  very  thinly. 

One  grain  of  thymol  to  1  oz.  of  oleate  of  zinc  is  also  agree- 
able and  beneficial. 

For  the  local  sweating  of  the  feet  no  plan  of  treatment 
gives  such  general  satisfaction  as  the  method  originally 
suggested  by  Hebra.1  The  diachylon  ointment  or  the 
unguentuin  vaselini  plumbicum  is  spread  over  a  piece  of 
linen  about  a  foot  square.  The  part  having  been  first 
washed,  and  well  dried,  is  then  enveloped  in  this  application, 
the  toes  at  the  same  time  being  kept  apart  by  pledgets  of 
lint  smeared  over  with  the  salve.  Care  must  be  taken  that 
the  foot  be  completely  covered,  and  that  the  dressing  be 
accurately  in  contact  with  the  skin.  After  the  completion 
of  the  operation  a  clean  stocking  is  put  on  and  over  all  a 
light,  new,  low  shoe.  In  twelve  hours  the  dressing  should 
be  removed,  the  foot  rubbed  with  a  dry  cloth,  or  a  dusting 
powder  applied  to  it. 

This  procedure  is  gone  through  with  twice  a  day  for 
from  eight  to  twelve  days.  In  the  mean  time  the  parts  must 
not  be  washed.  At  the  end  of  this  period  the  dressings  may 
be  removed  permanently,  and  the  use  of  the  dusting  powder 
continued  for  some  while  longer. 

After  a  few  days  the  thickened  cuticle  peels  off,  leaving 
the  surface  covered  with  a  clean,  white  skin.  When  the 
foot  has  become  normal  it  may  be  washed,  but  the  dusting 
powder  should  still  be  rubbed  in  for  a  few  weeks  longer. 
Sometimes  the  cure  is  permanent,  but  in  other  cases  a 
repetition  of  the  process  is  required. 

Thin  recommends  for  this  condition  dusting  the  shoes 
and  stockings  with  boric  acid,  the  wearing  of  cork  soles 
which  have  been  dipped  into  a  solution  of  boric  acid, 
and  a  boric  acid  ointment.  Morrow  speaks  well  of  foot 

1  Diseases  of  the  Skin,  vol.  i,  p.  89,  Sydenham  Society  Transac- 
tions, 1866. 


380  DISEASES  OF  THE  SWEAT  GLANDS 

baths  of  pinus  canadensis,  afterward  dusting  with  boric 
or  salicylic  acid  mixed  with  lycopodium.  Simply  strapping 
evenly  and  carefully  with  soap  or  lead  plaster  often  suffices. 
Noebe  advises  that  a  10  per  cent,  solution  nitrate  of  silver 
be  painted  on  the  sole  of  the  foot  and  between  the  toes 
every  day  until  the  horny  layer  is  shed. 

Ludwig  Weiss  extols  the  value  of  foot  baths  containing 
1  per  cent,  solution  of  potassium  permanganate  in  water  at 
a  temperature  of  1040.1 

We  have  elsewhere2  called  attention  to  the  fact  that 
sweating  of  the  feet  is  a  common  symptom  of  flat-foot,  and 
may  even  precede  that  malposition.  It  is  always  well, 
therefore,  to  look  to  the  anatomical  condition  of  the  feet, 
and,  where  flat-foot  exists,  to  have  it  remedied  by  suitable 
appliances. 

Among  other  recent  methods  of  treatment  of  hyperi- 
drosis  and  bromidrosis  may  be  mentioned  the  application 
of  tannoform,  which  is  a  powder  consisting  of  formalin  and 
tannin.  Under  this  treatment,  according  to  Frank,  the 
secretion  speedily  dminishes,  and  the  smell  in  bromidrosis 
passes  away.  Frey  recommends  a  2  per  cent,  solution  of 
formalin,  with  which  the  soles  and  interdigital  spaces  should 
be  washed  twice  a  day;  the  same  solution  may  be  employed 
to  wash  out  the  inside  of  the  shoes.  Heusner  advises  the 
following  wash:  Balsam  Peru,  15  gr. ;  formic  acid,  75  gr. ; 
chloral,  75  gr.;  alcohol,  1  oz.  This  may  be  applied  to 
local  areas  by  means  of  a  cotton  tampon,  and  for  general 
sweating  it  may  be  used  in  a  spray.  In  rebellious  cases  of 
local  sweating  the  solution  may  be  doubled  and  15  gr. 
of  trichloracetic  acid  may  be  added  to  it. 

We  can  speak  very  favorably  of  this  method  of  treatment. 

Stelwagon,  Bulkley,  and  Engman  have  reported  amelio- 
ration of  local  sweating  following  oxray  exposures.  Pusey's 
experience  is  that  "practically  in  all  cases  the  results  meet 

1  Journal  of  American  Medical  Association,  August  6,  1904. 

2  Hardaway,  Warty  Growths,  Callosities,  and  Hyperidrosis,  and 
their  Relation  to   Malposition  of  the   Feet,  Journal  of  Cutaneous 
Diseases,  March,  1906. 


HYPERIDROSIS  381 

the  exacting  demands  of  patients."  He  does  not  produce 
an  erythema.  Stelwagon  has  had  good  results  from  gal- 
vanism and  faradism  in  localized  forms,  especially  of  the 
hands. 

ADDITIONAL  PRESCRIPTIONS. 

J$ — Vaselini gr.  Ixxv 

Lanolini 3ijss 

Aqua? 3iv 

Acidi  salicylici gr.  vijss 

Liq.  formaldehyd n^xxxvij — M. 

S. — External  use.  Leredde. 

1$ — Liq.  ferri  persulphatis Syijss 

Glycerin! 3ijss 

Ol.  bergamottse 3v — M.* 

S. — Paint  on  soles  of  feet  and  between  toes.  Legoux. 

]$ — Acidi  salicylici 3ss-3ijss 

Zinci  oxidi, 

Talci  venet aa     3j — M. 

S. — To  be  dusted  on  freely  every  few  hours.      L.  Heitzmann. 

1$ — Pulv.  talcis 3x' 

Bismuthi  subnit 3xj 

Potassii  permang 5iij 

Sodii  sahcylatis 3ss — M. 

S. — Sprinkle  inside  the  stockings  in  bromidrosis.  Bardet. 

]} — Lanolini gr.  Ixxv 

Vaselini Sijss 

Liq.  formaldehyd 5ss-3j — M. 

S. — Rub  in  morning  and  evening.     If  irritation   occurs   suspend 
treatment  and  use  soothing  remedies.  Leistikow. 

1$ — Acidi  salicylici 3ss 

Acidi  tannici 5j 

Pulv.  marantre 3ss 

Pulv.  amyli 3ss — M. 

S. — For  sweating  feet.  Isadore  D\  <>r. 

T^ — Naphtholis oijss 

Aqua>  colognionsis 3vj 

Spt.  vini  gallici 3vss — M. 

S. — Local  use  in  hyperidrosis  of  palms  and  soles.       Kaposi. 


382  DISEASES  OF  THE  SWEAT  GLANDS 

Bromidrosis,  or  more  properly  osmidrosis,  is  a  functional 
disorder  of  the  sweat  glands,  in  which  the  perspired 
fluid  exhales  a  disagreeable  or  abnormal  odor.  The  quan- 
tity of  the  sweat  may  not  be  increased.  Bromidrosis,  or 
stinking  sweat,  is  most  frequently  of  a  local  character,  and 
may  have  its  seat  in  the  axillae,  about  the  genitals,  perineum, 
or  feet.  It  is  said  by  Thin  to  be  due  to  a  microorganism 
called  the  Bacterium  f  cetidum,  but  in  many  cases  no  special 
organism  can  be  found.  A  great  variety  of  odors  may  be 
present  in  the  sweat,  fragrant  or  the  reverse,  and  often 
connected  with  disorders  of  the  nervous  system. 

The  treatment  of  bromidrosis  is  considered  under  Hyper- 
idrosis. 

Chromidrosis  is  a  disorder  of  the  perspiratory  glands  in 
which  the  sweat  assumes  various  shades  of  color,  as  blue, 
red,  or  yellow. 

The  disease  is  most  frequently  observed  on  the  lower 
eyelids,  forehead,  cheeks,  abdomen,  and  scrotum.  Some- 
times a  fine,  brick-dust-like  deposit  is  seen  in  connection 
with  it,  or,  on  the  other  hand,  it  occurs  as  a  discoloration 
of  the  skin  and  even  of  the  fine  hairs.  Not  infrequently 
this  affection  is  feigned  by  hysterics.  The  causes  are 
obscure;  some  cases  have  been  thought  to  be  due  to  the 
presence  of  indican ;  in  others  bacteria  have  been  demon- 
strated; while  in  still  others  the  result  of  examinations 
was  negative. 

In  moist,  warm  parts  of  the  body  like  the  axilla?  and  the 
genital  regions,  red  sweat  has  been  observed,  concomitant 
with  the  concretions  on  the  hairs  known  as  lepothrix. 
Blue,  green,  and  red  sweat  is  at  times  caused  by  the  ingestion 
of  various  chemical  substances.1 

The  treatment  is  necessarily  conducted  on  general 
principles,  and  consists  in  removing  presumed  causative 

1  See  also  Heidingsfeld,  Journal  of  American  Medical  Association, 
December  13,  1902.  A  case  due  to  some  anomaly  of  pigmentation  in 
which  the  sweat  glands  were  healthy.  Other  conditions  such  as 
uridrosis,  phosphorescent  sweat,  and  hnniitii/ro.^in  may  IK*  mentioned 
in  this  connection. 


HIDRADENITIS  SUPPURATIVA  383 

conditions,  such  as  anemia,  hysteria,  uterine  disorders, 
etc.  In  a  case  observed  by  J.  C.  White  an  ointment  of 
boric  and  salicylic  acids  was  used  with  satisfactory  results. 
Red  chromidrosis  due  to  microorganisms  should  be 
treated  by  the  free  use  of  soap  and  water  and  the  applica- 
tion of  boric  acid  and  resorcin  lotions.  Bichloride  solution, 
1  to  1000,  and  washings  with  ether,  chloroform,  and  aro- 
matics  have  also  been  recommended. 

Anidrosis,  or  deficiency  of  sweat,  is  often  a  symptom  in 
general  diseases  such  as  diabetes  and  Bright's  disease,  and 
also  is  found  as  a  concomitant  in  varying  degrees  in  certain 
skin  affections,  e.  g.,  ichthyosis,  psoriasis,  general  eczema, 
the  atrophic  patches  of  leprosy,  scleroderma,  morphea,  etc. ; 
also  in  many  trophoneuroses  and  after  injuries  to  nerves. 
The  perspiratory  function  in  certain  persons  seems  in 
abeyance  even  under  circumstances  that  would  usually 
produce  free  sweating. 

The  treatment  of  this  condition  is,  as  a  rule,  the  treatment 
of  the  disorder  of  which  it  is  symptomatic.  Persons  having 
abnormally  dry  skins  can  be  made  more  comfortable  by 
the  use  of  bland  oils  and  salves.  (See  Ichthyosis.) 


HIDRADENITIS  SUPPURATIVA. 

Description. — This  is  a  suppurative  inflammation  of  a 
sweat  gland  resulting  in  its  destruction  and  the  production 
of  a  scar  (Pollitzer). 

The  lesions  may  be  few  or  numerous,  and  the  sites  of 
predilection  are  the  axilla,  anus,  nipple,  scrotum,  and  labia 
majora,  in  which  situations  they  are  apt  to  occur  singly, 
but  on  the  face  and  neck,  and  the  surface  of  the  body, 
they  generally  appear  in  large  numbers. 

The  eruption  begins  as  deep,  painless  subcutaneous 
nodules,  the  overlying  skin  being  freely  movable  and  of 
normal  color. 

In  the  course  of  some  weeks  the  lesion  enlarges  to  the 
size  of  a  pea,  the  skin  covering  it  becomes  red,  and  some 


384  DISEASES  OF  THE  SWEAT  GLANDS 

pain  is  felt  on  pressure.  If  the  tumor  be  punctured  a  few 
drops  of  pus  may  be  secured,  but  if  it  be  allowed  to  go  on 
undisturbed  the  growth  will  suppurate  and  leave  a  pig- 
mented  spot  that  ultimately  remains  as  a  slightly  depressed 
scar.  By  most  authorities  today  this  affection  is  regarded 
as  identical  with  or  allied  to  the  rather  vague  group  of 
diseases  known  variously  as  folliclis,  acnitis,  etc. 

The  treatment  is  that  of  acne  varioliformis.  One  of  us 
obtained  a  cure  of  one  case  and  improvement  of  another 
by  a  long  course  of  a;-ray  treatment. 


MILIARIA. 

Description. — Miliaria,  lichen  tropicus,  or  prickly  heat,  is 
an  acute  inflammatory  disorder  of  the  sweat  glands  char- 
acterized by  vesicles,  papules,  vesicopapules,  and  sometimes 
pustules.  As  ordinarily  encountered,  the  eruption  is  lim- 
ited to  the  trunk,  although  it  may  exist  elsewhere,  and 
consists  of  minute,  acuminated,  bright-red  papules,  to 
which  the  term  prickly  heat  is  popularly  applied. 

Sometimes  the  lesions  are  entirely  vesicular,  or  again, 
and  especially  on  the  face,  pustular,  or  a  mixture  of  pap- 
ules, vesicopapules,  and  vesicles.  The  eruption  comes 
out  suddenly,  usually  coincidently  with  profuse  sweating, 
and  in  favorable  cases  generally  subsides  with  slight 
desquamation  in  two  or  three  days.  The  subjective  symp- 
toms consist  of  most  annoying,  tingling,  burning,  and 
prickling  sensations.  Various  terms  are  used  to  indicate 
one  or  another  clinical  feature  of  the  affection,  viz.,  miliaria 
vesiculosa,  miliaria  papulosa,  miliaria  rubra,  miliaria  alba, 
etc.  The  pustular  form,  which  is  not  uncommon  in  this 
region,  is  not  usually  described  in  the  books.  We  have  seen 
many  examples  of  it  during  our  hot  summers.  Furuncu- 
losis  is  not  an  infrequent  sequel,  especially  in  children. 
Eczema  may  also  follow. 

Great  heat  of  any  sort  is  the  exciting  cause  and  conse- 
quently, as  would  be  expected,  the  disorder  is  most  fre- 


MILIARIA  385 

quent  in  summer.  Children  are  more  subject  to  prickly 
heat  than  adults,  and  the  obese  are  oftener  attacked  than 
the  lean.  It  is  especially  prone  to  occur  in  the  intemperate. 

Diagnosis.  —  Miliaria  differs  from  eczema  papulosum  in 
the  fact  that  the  lesions  of  the  latter  are  larger,  have  a 
longer  duration,  and  are  accompanied  by  greater  pruritus; 
and  from  eczema  vesiculosum  in  that  the  eczematous 
vesicles  are  more  closely  set,  and  rupture  more  speedily, 
giving  rise  to  a  characteristic  discharge.  The  occasional 
pustular  form  of  miliaria  sometimes  bears  more  or  less 
resemblance  to  smallpox  and  the  pustular  syphilide. 
Sudamina  are  not  inflammatory  in  character. 

Treatment.  —  As  it  is  rarely  possible  to  remove  the 
immediate  exciting  cause,  namely,  the  great  heat,  the 
patient  should  be  put  in  as  good  a  condition  as  practicable 
to  withstand  it.  This  may  be  accomplished  by  living  on 
a  diet  that  is  mainly  farinaceous,  by  abstaining  from  alco- 
holic stimulants,  and  by  wearing  suitable  garments.  Chil- 
dren especially  are  often  cruelly  swathed  in  flannels  and 
other  heavy  clothing.  In  an  acute,  extensive  eruption, 
in  the  adult,  the  citrate  of  potassium  in  the  form  of  the 
granulated  effervescent  salt  is  agreeable  and  useful.  Tonics 
are  sometimes  demanded  in  relapsing  cases;  in  the  majority, 
however,  internal  treatment  is  not  required.  Locally,  the 
most  speedy  relief  may  be  obtained  from  the  zinc  and 
calamine  lotion: 


1$  —  Acidi  carbolic!    ......... 

(vel  liq.  carbonis  detergentis) 

Lotionis  zinci  et  calaminse      .....  5iv  —  M. 
S.  —  Mop  on  freely. 

Anderson's  dusting  powder  is  also  beneficial: 

1^  —  Pulv.  amyli  ..........  ovj 

Zinci  oxidi    ..........  5jss 

Pulv.  camphor*  ........  O^ss  —  M. 

S.  —  Dusting  powder. 


25 


386  DISEASES  OF  THE  SWEAT  GLANDS 


SUDAMEN. 

Description. — This  is  a  non-inflammatory  affection  of  the 
sweat  glands  in  which  small  pin-point,  or  slightly  larger, 
clear  vesicles  appear  upon  the  skin.  They  have  been  com- 
pared not  inaptly  to  dewdrops,  and  are  usually  observed 
upon  the  skin  in  great  numbers,  closely  set,  yet  discrete, 
and  possessing  a  pearly  lustre.  They  are  entirely  without 
inflammatory  hue,  and  are  not  surrounded  by  an  areola. 
They  do  not  become  purulent,  and  the  vesicle  wall  does 
not  rupture,  but  their  contents  undergo  absorption,  and  the 
lesion  disappears  with  a  branny  desquamation.  Sudamina 
are  prone  to  attack  the  thin  portions  of  the  skin;  on  the 
face  the  lesions  are  deeper-seated  and  more  persistent. 

Sudamina  are  observed  in  connection  with  conditions  of 
general  debility  and  in  febrile  disorders;  on  the  other  hand, 
even  in  perfectly  healthy  persons,  where  there  is  excessive 
formation  of  sweat,  the  same  disorder  may  be  induced. 

Treatment. — Removal  of  the  exciting  cause  is  the  main 
indication  for  general  treatment.  Locally,  the  application 
of  dusting  powders  of  lycopodium  and  oxide  of  zinc,  or  of 
starch,  are  demanded. 


HIDROCYSTOMA. 

Description. — This  condition  was  first  described  by  A. 
R.  Robinson  in  1884,  but  more  fully  some  years  afterward. 
Since  that  time  a  number  of  cases  have  been  published. 
The  following  description  is  taken  from  Robinson's  account 
of  the  disorder: 

The  eruption  occurs  upon  the  lower  part  of  the  forehead, 
the  orbital  region,  nose,  cheeks,  and  often  upon  the  upper 
and  lower  lips  and  the  chin.  The  eruption  has  never  been 
observed  elsewhere  on  the  body.  When  few  lesions  are 
present  they  are  generally  discrete;  if,  however,  they  are 
very  numerous  they  may  be  more  closely  set.  The  indi- 


GRANULOSIS  RUBRA  NASI  387 

vidual  elements  appear  as  tense,  shiny,  clear  vesicles  that 
vary  in  size  from  a  pin's  head  to  a  pea,  and  are  of  a  round, 
obtuse,  or  ovoid  form.  They  are  deep-seated,  and  the 
smaller  lesions  resemble  a  boiled  sago  grain;  the  larger 
lesions  present  a  "darkish-blue"  tint.  When  the  contents 
dry  up  the  lesions  have  a  milium-like  aspect. 

The  vesicle  contents  are  clear  and  remain  so,  and  unless 
accidentally  ruptured  the  lesions  dry  up  after  an  existence 
of  one  or  more  weeks.  The  skin  of  the  involved  area  may 
be  left  in  a  normal  state  or  else  exhibit  slight  temporary 
pigmentation.  Subjective  symptoms  are  mostly  absent, 
or  there  may  be  some  degree  of  tension  and  smarting. 
Most  of  the  patients  are  women  in  middle  life  who  perspire 
easily,  and  who,  like  washerwomen,  are  exposed  to  much 
heat  and  moisture.  The  eruption  is  worse  in  summer  than 
in  winter.  The  lesions  are  cysts  of  the  sweat  ducts  filled 
with  sweat. 

Treatment. — Avoidance  of  the  known  causes  of  the  dis- 
ease constitutes  the  prophylactic  treatment.  The  actual 
lesions  may  be  punctured. 


GRANULOSIS  RUBRA  NASI. 

Description. — This  disorder  usually  occupies  the  end  and 
sides  of  the  nose,  but  may  at  times  be  seated  on  the  upper 
lip,  cheeks,  and  eyebrows.  The  involved  area  is  of  a  red 
color,  over  which  may  be  observed  minute  papules  and 
macules  of  a  deep-red  or  brownish-red  hue,  which  may 
be  made  to  disappear  under  pressure. 

There  is  a  coincident  hyperidrosis  of  the  affected  region, 
and  drops  of  sweat  may  be  often  observed  interspersed 
among  the  other  lesions.  The  disease  runs  a  chronic 
course.  Its  subjects  have  been  young  children  of  delicate 
constitution. 

Treatment. — The  treatment  is  not  satisfactory.  Linear 
scarification  has  been  suggested. 


388        DISEASES  OF  THE  SEBACEOUS  GLANDS 

DISEASES  OF  THE  SEBACEOUS  GLANDS. 
SEBORRHEA. 

Description. — Seborrhea,  sometimes  also  called  steator- 
rhea,  is  a  functional  disease  of  the  sebaceous  glands 
characterized  by  excessive  secretion  of  sebaceous  matter, 
which  is  deposited  on  the  skin  in  the  form  of  oily,  scaly,  or 
crusted  material. 

Seborrhea  is  one  of  the  commonest  of  skin  affections, 
but  since,  when  uncomplicated,  it  occasions  little  or  no 
inconvenience,  the  disorder  chiefly  comes  under  medical 
observation  as  a  part  of  a  general  condition  which  may 
include  acne,  loss  of  hair,  etc.  It  was  formerly  the  cus- 
tom to  divide  seborrhea  into  two  varieties,  namely,  seb- 
orrhea  oleosa  and  seborrhea  sicca,  but  of  recent  years  the 
atter  term  has  been  dropped,  since  it  is  held  that  cases  of 
the  so-called  dry  form  are  inflammatory  in  character,  and 
represent  more  properly  the  condition  described  elsewhere 
as  seborrheal  eczema.  We  still,  however,  recognize  with 
Stelwagon  and  others  a  condition  in  which  there  is  a  for- 
mation of  crusts  and  scales  without  inflammation,  but  we 
must  admit  that  the  "step  from  seborrhea  to  eczema 
seborrheicum  is  often  a  short  one." 

Seborrhea  of  the  Scalp. — A  certain  amount  of  sebor- 
rhea of  the  scalp  may  persist  in  newborn  children,  and  the 
effort  to  remove  it  by  washing,  combing  and  other  harsh 
measures  is  not  an  infrequent  cause  of  eczema.  Unmixed 
seborrhea  is  comparatively  infrequent  in  the  adult  scalp, 
and  is  said  to  be  more  apt  to  attack  persons  having  black 
hair.  In  these  cases  the  hair  is  shiny  and  greasy  to  the 
touch  and  often  matted  together.  Unless  scrupulous 
cleanliness  is  observed,  the  parts  become  very  foul  from  the 
collection  of  impurities,  and  an  accompanying  dermatitis 
may  occur  as  a  complication. 

In  the  crusted,  scaly  form  we  find  thin,  greasy,  ad  he- 


SEBORRHEA  389 

rent  scales  about  the  openings  of  the  hair  follicles,  or 
attached  to  the  hair,  or  heaped  up  in  greasy  masses  more 
or  less  firmly  adherent  to  the  scalp.  The  underlying  skin 
is  generally  pale  or  even  ashen  in  color;  but  at  times  from 
scratching,  pruritus  often  being  present,  the  scalp  may  be 
reddened,  or  here  and  there  will  exhibit  moist  spots  that 
readily  crust  over.  Seborrhea  of  the  bearded  face  and  eye- 
brows is  also  observed.  In  seborrhea  the  nutrition  of  the 
hair  is  interfered  with,  and  baldness  may  ensue;  but  in  our 
experience  this  result  is  by  no  means  inevitable. 

Seborrhea  of  the  Face. — A  general  unctuous  condition 
of  the  face  is  common  with  a  great  many  persons,  and  an 
oily  condition  of  the  nose,  which  at  the  same  time  is  of  a 
bluish-red  color  to  the  eye  and  cold  to  the  touch,  is  fre- 
quently seen  in  chlorotic  and  strumous  young  people.  Very 
often,  as  a  result  of  squeezing  and  pinching,  the  member 
becomes  large  and  flabby.  The  region  behind  the  ears, 
at  the  sides  of  the  nose,  and  the  corners  of  the  mouth  are 
common  seats  of  seborrhea. 

Seborrhea  of  the  umbilicus,  often  leading  to  inflamma- 
tory conditions  (seborrheal  eczema),  is  comparatively  fre- 
quent. A  form  of  general  seborrhea  is  sometimes  seen  in 
both  children  and  adults. 

Among  the  predisposing  causes  usually  ascribed  for  the 
production  of  seborrhea  are  chlorosis,  dyspepsia,  wasting 
diseases,  and  various  disturbances  of  nutrition.  In  many 
instances  the  cause  is  not  apparent.  The  seborrheic 
condition  of  the  skin  that  follows  smallpox,  and  also  that 
which  becomes  established  in  syphilis,  are  well  known. 

The  view  that  seborrhea  is  of  parasitic  origin  and  con- 
tagious is  held  by  some  eminent  authorities,  but  in  no 
way  interferes  with  the  idea  that  a  certain  soil  may  be 
necessary  for  the  growth  and  multiplication  of  the  noxious 
organisms.  Unna's  belief  that  the  sweat  glands  supply 
the  fatty  secretion  is  well  known. 

Prognosis. — It  is  not  difficult  to  remove  temporarily  a 
seborrhea.,  but  relapses  are  to  be  expected.  The  disease 
in  infants  is  easy  to  manage,  and  genital  seborrhea  is  quite 
amenable  to  treatment. 


390         DISEASES  OF  THE  SEBACEOUS  GLANDS 

Treatment. — In  all  cases  of  seborrhea  it  is  important  to 
correct  any  derangements  of  the  health  that  may  be  present, 
and  to  place  the  patient  under  the  best  hygienic  conditions. 
To  these  ends  the  diet  should  be  regulated,  dyspepsia 
removed,  and  such  other  measures  advised  as  the  special 
necessities  of  the  case  may  warrant.  Iron  is  often  indicated, 
and  may  be  given  in  the  form  of  Blaud's  pills  with  nux 
vomica,  or  as  a  wine  of  iron  with  Fowler's  solution.  Robust 
persons  who  may  be  suffering  from  a  deranged  digestion 
and  constipation  are  often  benefited  by  the  mistura  ferri 
acida  of  Startin.  We  have  not  seen  any  result  from  the 
administration  of  the  sulphide  of  calcium,  but  we  believe 
that  the  long-continued  use  of  sulphur  in  the  form  of 
Garrod's  lozenges  is  beneficial.  Elliot  advises  ichthyol 
internally,  beginning  with  one  5-gr.  capsule,  three  times  a 
day,  and  gradually  increasing  to  five  or  more  during  the 
same  period. 

The  local  treatment  is  of  much  importance.  It  is  first 
necessary  to  remove  all  crusts  and  scales,  particularly  from 
the  scalp.  This  may  be  accomplished  where  the  crusts  are 
thick  and  tenacious,  by  soaking  the  parts  over  night  with 
olive  oil  under  a  flannel  cap,  and  then  washing  freely  next 
morning  with  equal  parts  of  green  soap  and  alcohol.  At 
other  times  the  simple  washing  with  the  soap  spirit  is 
sufficient.  Of  all  the  preparations  that  have  been  advised 
for  seborrhea,  sulphur  gives  the  speediest  and  most  satis- 
factory results.  We  usually  combine  a  small  quantity  of 
salicylic  acid  with  it: 

1$ — Sulphuris  prsecipitati 5j-  5ij 

Acidi  salicylic! 9j 

Vaselini 5j 

Olei  limonis q.  s. — M. 

S. — Apply  a  small  quantity  once  or  twice  in  the  day. 

If  this  or  any  other  greasy  application  is  used  on  the 
scalp,  it  will  be  necessary  to  direct  the  patient  to  employ 
the  shampoo  every  four  or  five  days  or  even  oftener.1 

1  When  ordering  the  shampoo  for  the  first  time  it  is  advisable  to 
warn  the  patient  that  probably  a  great  many  loose  hairs  will  come 
away,  else  the  physician  will  be  blamed  for  prescribing  unduly  strong 
remedies. 


SEBORRHEA  391 

For  seborrhea  of  the  scalp  Vidal  suggests  the  following : 

1$ — Sulphuris  praecipitati 5ss 

Olei  ricini 3ij 

Olei  theobromae 5iij 

Balsami  peruviani 3ss — M. 

Mix  the  sulphur  and  castor  oil  thoroughly,  then  add  the  cocoa 
butter  by  aid  of  a  gentle  heat,  and  finally  the  balsam. 
S. — Rub  into  scalp  morning  and  evening. 

Bronson's  pomade  is  also  very  serviceable  in  the  same 
condition : 

1$ — Hydrarg.  ammoniati 9j 

Hydrarg.  chloridi  mitis 9ij 

Vaselini 5j — M. 

S. — Apply  once  or  twice  daily. 

Elliot  particularly  recommends  resorcin,  3  to  12  per  cent, 
strength,  preferably  in  alcoholic  solution. 

Various  mercurial  preparations,  tar,  tannin,  chloral,  and 
carbolic  acid  have  also  been  recommended. 

According  to  Morrow,  for  seborrhea  of  the  face,  after 
the  crusts  have  been  removed,  the  following  is  an  excellent 
application : 

1$ — Sulphuris  praecipitati, 

Spiritus  odorati aa    3ss 

Amyli  mucilaginis 5iv — M. 

S. — To  be  applied  at  night,  the  following  morning  to  be  washed 
off,  and  the  affected  surfaces  to  be  powdered  with  sulphur,  1  part,  to 
fuller's  earth,  7  parts. 

Oily  seborrhea  of  the  nose  is  sometimes  much  improved 
by  mopping  with  the  zinc  and  sulphuret  of  potassium 
lotion : 

1$ — Zinci  sulphatis, 

Potassii  sulphuratae aa    oj 

Sulphuris  prsecip 5j 

Aquae  rosae 5iv — M. 

S. — External  use. 

Mopping  the  part  with  ether  will  remove  the  oiliness 
temporarily.  A  superfatted  soap  containing  sulphur  and 
salicylic  acid  is  also  useful.  The  following  lotion  is  agree- 
able. 


392         DISEASES  OF  THE  SEBACEOUS  GLANDS 

ty — Acidi  borici 3jj 

Alcoholis 5iv — M. 

8. — Mop  on  with  rag  several  times  daily  or  whenever  the  face  is 
"shiny." 

For  seborrhea  of  the  trunk  the  same  remedies  may  be 
used  as  in  other  localities,  the  sulphur  and  resorcin  prepa- 
rations giving,  however,  the  best  results.  The  following 
formula  is  useful: 

J$ — Resorcini gr.  x-xx 

Zinci  oxidi oss 

Sulphuris  prsecipitati oj 

Vaselini 5j — M. 

Seborrhea  of  the  genitals  requires  absolute  cleanliness 
and  the  local  use  of  an  alum  or  tannin  wash. 


ADDITIONAL  PRESCRIPTIONS. 

R> — Hydrarg.  ammoniati gr.  xx 

Acidi  carbolici gr.  v 

Ung.  aquae  rosae q.  s.  ad  3j — M. 

S. — For  the  scalp.  Wolff. 


1$ — Olei  rusci gtt.  xv-5ijss 

Olei  ricini oj-5ij 

Olei  bergamottse  et 

Olei  citronellae aa     gtt.  xv 

JEther.  sulphurici 9ij 

Alcoholis  fort q.  s.  ad     5vij — M. 

S. — Apply  once  daily  with  a  bristle  brush.    For  the  scalp. 

L.  Heitzmann. 

1^ — Liq.  carbonis  deterg tr\iv-n\x 

Glycerin! 3ss 

Aquas  rosae q.  s.  ad     3j — M. 

S. — Local  use.    For  the  scalp.  J.  F.  Payne. 


1$ — Olei  amygdahc  dulcis oj 

Acidi  carbolici gtt.  xx 

Olei  limonis 3j 

Aq.  destillatse 5iij — M. 

S. — Local  use.    For  the  scalp  Van  Harlingen 


^ — Olei  rusci 
Vaselin.  alb. 
Paraffini 
Olei  bergamottae 
Ol.  citronellae 


COMEDO  393 

3JVSS 

5yss 
3jss 
"or  the  scalp.  L.  Heitzmann. 


S. — Rub  in  with  fingers.    ] 

1$ — Acidi  tannici 3j 

Vaselini 5j — M. 

S. — Local  use.    For  the  scalp.  Tilbury  Fox. 


COMEDO. 

Description. — This  is  a  disorder  of  the  sebaceous  glands 
in  which  their  excretory  ducts  are  plugged  up  by  hardened 
sebum  mixed  with  epithelial  cells.  According  to  Unna 
comedones  are  not  the  result  of  an  abnormal  secretion  of 
sebum,  but  a  product  of  hyperkeratosis  extending  from  the 
general  surface  to  the  mouths  of  the  follicles,  and  which 
contain,  in  addition  to  horny  substance,  normal  sebum. 
For  Sabouraud  the  comedo  is  a  huge,  degenerated  sebor- 
rheic  cocoon,  and  acne  polymorphe  is  a  further  manifestation 
of  this  same  degeneration. 

The  accumulations  are  usually  black-topped,  looking 
like  grains  of  gunpowder,  and  cause  elevations  of  pin- 
point to  pin-head  size;  sometimes  there  is  slight  depression. 
If  the  skin  be  compressed  on  both  sides  of  one  of  these 
little  papules,  a  filiform,  white  or  yellowish  mass  may  be 
extruded.  Cases  of  double  comedo  have  been  observed 
(Ohmann-Dumesnil).  The  usual  situations  of  comedones 
are  the  nose,  forehead,  cheeks,  chin,  inside  of  ears,  and  also 
the  chest  and  back.  Comedones  are  present  in  all  cases  of 
acne.  Crocker  and  others  also  report  comedones  as  occur- 
ring in  children;  on  the  temples  in  girls,  the  occiput  and 
forehead  in  boys,  and  the  cheeks  in  infants. 

Grouped  comedones  have  been  described  by  Thin  and 
Crocker,  which  are  said  to  occur  mainly  in  the  "flush  area 
of  the  face,  but  also  on  the  trunk."  According  to  1'nna 
the  black  heads  of  the  sebaceous  plugs  are  due  to  pigmented 


394        DISEASES  OF  THE  SEBACEOUS  GLANDS 

granules  and  not  to  accumulation  of  atmospheric  dirt,  as 
commonly  supposed.  The  microbacillus  found  in  the 
comedo  plug  is  looked  upon  by  Unna,  Sabouraud,  and 
others  as  the  essential  factor  in  the  production  of  come- 
dones. The  affection  is  most  frequent  in  persons  having 
a  coarse  skin,  is  due  in  most  cases  in  part  at  least  to  dis- 
orders of  digestion,  and  is  also  found  in  those  suffering 
from  various  so-called  strumous  states. 

Prognosis. — This  is  generally  favorable,  although  the 
condition  is  often  very  unyielding. 

Treatment. — Attention  to  diet,  general  hygiene,  etc.,  as 
in  acne,  are  prerequisites  to  a  successful  issue.  Locally, 
stimulating  measures  are  to  be  advised,  together  with  the 
expression  of  the  sebaceous  plugs.  For  the  latter  purpose 
Piffard's  ingenious  comedo  spoon  may  be  employed.  The 
following  lotion  may  be  used  every  night: 

1$ — Saponis  olivse  prsep., 

Alcoholis aa     3j 

Aquae  rosae 5vij — M. 

S. — Rub  in  with  a  piece  of  dampened  flannel. 

If  the  face  is  made  rough  by  these  frictions,  cold  cream 
may  be  smeared  on  in  the  morning.  The  superfatted  soaps 
mentioned  under  acne  are  also  beneficial. 

Unna  recommends  a  paste  of  this  sort: 

I$— Aceti 3ij 

Glycerini ojij 

Kaolini 3iv — M. 

S. — Smear  over  surface  at  night. 

Permanent  obliteration  of  the  sacs  may  be  obtained  by 
inserting  an  electrolytic  needle  for  a  few  seconds. 

Preparations  of  sulphur  we  regard  as  objectionable,  as 
this  drug  apparently  seems  to  increase  the  number  of  black 
heads. 

The  x-rays  and  actinotherapy  have  also  been  employed 
in  treatment.  In  obstinate  comedones  on  the  back,  we 
have  had  excellent  results  from  the  x-rays. 

Stelwagon  advises  eight  or  ten  mild  to  moderate  sittings 
to  contract  patulous  ducts.  He  also  found  a  fairly  strong 


MILIUM  395 

faradic  current  two  or  three  times  a  week  of  material 
advantage  in  his  cases. 


MILIUM. 

Description. — The  usual  definition  of  milium  is  a  little 
subepidermic  cyst  caused  by  retention  of  secretion  in  a 
sebaceous  gland.  A.  R.  Robinson,  however,  has  shown 
that  they  are  sometimes  due  to  the  snaring  off  of  a  group 
of  cells  from  a  hair  follicle  or  the  deep  epithelium. 

Milia  occur  for  the  most  part  on  the  face,  especially 
under  the  eyes,  over  the  cheeks,  and  on  the  forehead.  They 
are  of  a  whitish  or  yellowish  color,  and  vary  in  size  from  a 
pin-point  to  a  pin-head,  and  in  numbers  from  two  or  three 
to  dozens.  When  found  upon  the  penis  and  scrotum 
they  are  much  larger  than  elsewhere.  They  remain  un- 
changed for  years,  but  sometimes  the  contents  undergo  a 
calcareous  degeneration,  forming  the  so-called  cutaneous 
calculi.  It  is  not  uncommon  to  find  milia  on  the  faces  of 
newborn  children  (strophulus  albidus),  but  it  is  to  be 
noted  that  Phillipson  regards  these  as  sebaceous  cysts. 
They  are  often  seen  in  connection  with  acne,  also  on  the 
sites  of  pemphigus  bullae,  and  in  the  wake  of  various  ulcera- 
tive  and  atrophic  conditions.  A  large,  flat  variety  occur- 
ring in  patches  on  the  eyelids  may  be  mistaken  for  xan- 
thoma  and  perhaps  for  molluscum  epitheliale. 

Treatment. — They  may  be  readily  shelled  out  after  a 
superficial  incision,  but  by  far  the  most  ready  method,  as 
originally  suggested  by  one  of  us,1  is  to  puncture  each 
little  tumor  with  a  fine  needle  attached  to  the  negative 
pole  of  a  galvanic  battery. 

When  the  milia  are  very  small  and  numerous,  Wolff 
recommends  exfoliating  the  skin  with  a  50  per  cent,  resor- 
cin  paste  or  a  strong  salicylic  acid  solution  in  collodion. 

1  Hardaway. 


396         DISEASES  OF  THE  SEBACEOUS  GLANDS 

ATHEROMA. 

Description. — In  size  atheromata  or  wens  vary  from  a 
pea  to  that  of  an  orange.  They  occur  as  round,  sometimes 
slightly  flattened  swellings  that  are  elastic  to  the  touch. 
The  tumor  usually  slides  freely  over  the  underlying  tissues, 
but  the  skin  over  it,  though  normal  in  appearance,  is  often 
adherent  to  the  growth.  Often  at  the  apex  of  the  cyst  may 
be  seen  a  black  point,  which  represents  an  opening  into 
the  cavity  of  the  tumor,  through  which  a  thick,  whitish 
mass,  often  with  a  fetid  odor,  may  be  squeezed.  An  athe- 
roma  may  suppurate  spontaneously  or  after  injury;  after 
discharging  its  contents  an  ulcer  covered  with  fungous 
granulations  may  be  left  which  may  closely  resemble  an 
epithelioma.  At  other  times,  after  the  rupture  of  the  cyst, 
a  cutaneous  horn  forms.  In  old  cysts  the  contents  undergo 
a  calcareous  change.  Atheromata  usually  occur  on  those 
parts  normally  supplied  with  sebaceous  glands,  as  (he  face, 
head,  neck,  and  back,  but  exceptionally  they  have  been 
observed  in  regions  not  supplied  with  sebaceous  glands, 
such  as  the  palms  and  soles.  Some  of  these  cysts  are 
doubtless  the  result  of  occlusion  of  the  ducts  of  sebaceous 
glands,  with  consequent  accumulation  of  the  secretions, 
while  most  of  them,  as  Franke  and  Torok,  and,  later, 
Chiari,  have  shown,  are  in  reality  allied  to  dermoids. 

Treatment. — In  most  cases  the  best  treatment  of  ather- 
oma  is  to  divide  the  skin  down  to  the  wall  of  the  cyst, 
and  then  to  dissect  out  the  sac,  taking  care  not  to  rupture 
it.  Another  method  is  to  split  open  the  sac,  and,  seizing 
its  thick  lining  membrane  with  forceps,  to  drag  it  from  its 
attachments:  by  this  method  there  is  liability  to  recur- 
rence, as  some  fragments  of  the  secreting  membrane  may 
be  left  behind.  Lutz,  of  Honolulu,  speaks  in  high  terms 
of  the  use  of  iodine  to  cause  an  obliterating  inflammation. 
The  tumor  is  split  open,  contents  evacuated,  and  interior 
painted  with  tincture  of  iodine.  This  is  of  especial  appli- 
cation where  the  skin  is  so  firmly  adherent  to  the  sac  as 
to  make  it  difficult  to  dissect  it  out.  In  small  growths,  after 
extrusion  of  the  contents,  electrolysis  may  be  employed. 


ACNE  307 

ACNE. 

Description. — Acne  is  an  inflammatory  disease  of  the 
sebaceous  glands,  occurring  mostly  about  the  face  and 
back,  and  characterized,  according  to  the  intensity  of  the 
process,  by  papular,  pustular,  or  tubercular  lesions.  It 
is  rare  to  find  an  acne  that  is  purely  papular  or  purely 
pustular,  although  one  or  the  other  form  of  lesion  may  pre- 
dominate. The  eruption  is  most  frequently  to  be  found 
upon  the  face,  shoulders,  chest  and  back,  but  it  may  occur 
wherever  there  are  sebaceous  glands,  affecting  more  par- 
ticularly, however,  those  connected  with  rudimentary  hairs. 
The  most  common  seat  of  the  disease  is  the  face,  to  which 
region  it  may  be  entirely  confined,  or  be  conjoined  with 
more  or  less  eruption  elsewhere.  In  other  instances  the 
shoulders  and  back  may  be  the  only  parts  attacked.  Acne 
is  generally  complicated  with  more  or  less  comedo  and 
seborrhea.  As  a  matter  of  fact  it  is  held  that  acne  finds 
its  explanation  in  seborrhea  and  the  comedo,  although 
there  is  some  difference  of  opinion  as  to  their  relationship 
to  each  other.  Clinically,  some  acne  cases  do  not  exhibit 
seborrhea,  and  every  comedo  does  not  develop  into  an 
inflammatory  lesion.  As  a  rule,  it  is  a  chronic  affection, 
running  its  course  slowly,  and  kept  up  by  the  appearance, 
from  time  to  time,  of  new  crops  of  papules  or  pustules. 
Subjective  symptoms  are  not  very  marked.  The  number 
of  acne  lesions  present  in  a  given  case  may  vary  from  two 
or  three  to  several  dozen. 

For  practical  purposes  it  is  well  to  recognize  two  clinical 
varieties  of  acne,  viz.,  acne  simplex  and  acne  indurata: 

Acne  Simplex. — Hie  eruption  is  usually  made  up  of 
papules,  papulopustules,  and  pustules.  In  some  cases 
small,  red  pimples  predominate  (acne  papulosa),  which  are 
somewhat  conical  in  shape,  and  present  at  their  apices 
minute  yellowish  or  blackish  points  corresponding  to  the 
ducts  of  the  sebaceous  glands.  The  more  frequent  variety 
of  acne  simplex,  however,  is  the  papulopustular,  with  the 
pustules  in  excess  (acne  pustulosa).  The  pustules  are 
freely  dispersed  over  the  invaded  surface,  have  a  somewhat 


398         DISEASES  OF  THE  SEBACEOUS  GLANDS 

globular  shape,  and  are  seated  upon  an  inflamed  base. 
They  vary  from  pin-head  to  split-pea  size. 

Suppuration  may  be  abundant  or  slight;  in  acne  simplex 
the  evolution  of  the  pustule  is  rapid ;  it  may  either  rupture 
and  discharge  its  contents,  or  undergo  absorption  and 
desiccation. 

Acne  Indurata. — This  form  differs  in  no  way  patholog- 
ically from  the  common  variety,  except  in  the  extent  of  the 
inflammatory  process.  In  acne  indurata  the  inflammation 
is  deeper  seated;  the  subcutaneous  connective  tissue  may 
be  involved;  there  may  be  considerable  swelling  of  the  parts, 
and  quite  large  subcutaneous  abscesses  may  even  form. 
The  tubercles  are  usually  slow  in  development  and  indolent 
in  their  course;  in  fact,  a  hard,  inflamed  nodule  may  exist 
many  days  before  suppuration  can  be  detected.  Indelible 
cicatrices  often  result. 

The  so-called  acne  artificialis  due  to  the  ingestion  or 
topical  application  of  certain  substances,  e.  g.,  iodine, 
bromine,  tar,  etc.,  calls  for  no  especial  description.  The 
eruptions  thus  caused  may  be  slight  or  exceedingly  severe. 
Acne  cachecticorum  or  scrofulosorum  occurs  in  the  form  of 
livid-red,  pin-head  to  lentil-sized,  soft,  flat  papules  and 
pustules  (Kaposi)  that  are  usually  found  on  the  extremities 
of  ill-nourished,  strumous  persons.  T.  C.  Fox  calls  atten- 
tion to  an  eruption  of  similar  character  in  young  children. 

In  this  connection  may  be  mentioned  the  acne  urticata 
of  Kaposi,  which  appears  in  the  form  of  an  acute  develop- 
ment of  pale-red,  wheal-like  elevations  of  the  size  of  a  bean 
to  that  of  a  twenty-five-cent  piece.  Itching  and  burning 
are  marked.  The  lesions  spontaneously  subside  in  a  few 
hours  or  two  or  three  days,  but  often  from  scratching  and 
squeezing  the  papules  become  indurated  and  crusted,  and 
leave  brown,  cicatricial  streaks  in  their  wake.  Frequent 
exacerbation  is  the  rule.  This  disorder  can  scarcely  be 
considered  an  acne  in  the  ordinary  sense. 

Crocker,  under  the  title  of  acne  keratosa,  describes  a  rare 
acneiform  eruption  that  seems  to  resemble  acne  urticata. 
The  papules  are  accompanied  by  severe  itching,  and  begin 
also  as  urticaria-like  elevations,  but  in  acne  keratosa  the 


ACNE  399 

lesions  contain  one  or  more  conical  plugs  about  one-tenth 
inch  long,  which  seem  to  be  the  source  of  irritation. 

Etiology. — Acne  of  the  ordinary  type  does  not  usually 
attack  children.  It  is  most  common  from  the  age  of  puberty 
up  to  the  age  of  twenty-four  or  thereabouts,  although  it  may 
occur  in  more  mature  years.  Acne  may  persist  for  a  life- 
time, but  the  great  majority  of  cases  tend  to  spontaneous  re- 
covery, at  various  periods,  within  the  extremes  stated  above. 

Next  to  eczema,  acne  is  one  of  the  most  frequent  diseases 
of  the  skin;  indeed  if  all  persons  affected  with  it  were  to 
seek  the  aid  of  a  physician,  there  is  no  question  that  it 
would  occupy  the  first  place  in  our  statistical  tables.  Acne 
is  found  under  all  conditions  of  life,  in  all  climates,  and  in 
both  sexes  equally.  Uterine  and  gastro-intestinal  derange- 
ments are  frequent  accompaniments  of  the  disease. 

Many  authorities,  following  Unna,  Sabouraud,  and  Gil- 
christ,  are  committed  to  the  belief  that  acne  is  a  parasitic 
disease  due  to  a  special  organism,  although  acknowledging 
the  necessity  of  a  favorable  soil  for  its  production. 

Gilchrist  goes  so  far  as  to  suggest  that  certain  consti- 
tutional conditions,  heretofore  regarded  as  causing  the 
disease,  may  be  produced  by  absorption  of  the  toxins  of 
the  acne  bacillus. 

Diagnosis. — The  diagnosis  of  acne  presents  few  diffi- 
culties. A  papulopustular  or  tubercular  syphilide  may 
simulate  an  acne,  and  the  same  may  be  said  of  smallpox, 
but  an  error  is  next  to  impossible  with  moderate  care. 

Prognosis. — The  prognosis  of  acne  is  essentially  favor- 
able; that  is  to  say,  it  is  in  no  way  dangerous  to  life,  and 
in  most  cases  tends  to  spontaneous  recovery  in  the  course 
of  months  or  years.  It  rarely  persists  through  life,  but  in 
serious  cases  great  disfigurement  may  ensue  in  the  shape 
of  cicatrices,  or  even  keloidal  growths,  which  latter,  how- 
ever, generally  disappear  in  time.  The  removal  of  existing 
lesions  is  not  usually  difficult;  the  prevention  of  relapse 
will  sometimes  tax  the  ingenuity  of  the  physician  to  the 
utmost.  Strange  as  it  may  seem,  severe  cases  are  more 
manageable  than  light  cases;  but,  taken  all  in  all,  the  prog- 
nosis may  be  regarded  as  good. 


400         DISEASES  OF  THE  SEBACEOUS  GLANDS 

Treatment. — Hygienic  and  dietetic  measures  are  urgently 
demanded  in  most  cases.    Under  the  first  head  are  to  be 
recommended  the  tepid  or  cold-sponge  bath,  followed  by 
brisk  friction  of  the  skin,  which  should  be  taken  every 
morning,  and  also  one  or  more  Turkish  baths  a  week. 
Patients  should  be  encouraged  to  take  regular  exercise, 
preferably  in  the  form  of  a  walk  of  a  half-hour's  duration, 
morning  and  evening,  although  in  weakly  persons  this 
should   be  approached  gradually,  as    undue    fatigue    is 
always  objectionable.  Well-ventilated  apartments  and  early 
hours  should  be  insisted  upon.     As  many  acne  patients 
suffer  from  dyspepsia  and  constipation,  it  is  better  to  over- 
come these  states  by  judicious  feeding  and  regular  habits, 
than  by  drugs,  which  only  palliate  and  do  not  cure.    Stimu- 
lating foods  and  drinks,  such  as  soups,  spices,  gravies, 
pickles,  cheese,  wine,  beer,  spirits,  tea,  and  coffee  should  be 
prohibited.     Oatmeal,  hot  and  fresh  breads  and  cakes, 
pastry  and  fried  foods  generally  are  particularly  obnoxious. 
Sweets  and  all  kinds  of  nuts  are  to  be  avoided.    Patients 
should  be  encouraged  to  drink  milk1  where  it  agrees,  and 
to  eat  broiled  beaf steak,  mutton  chop,  roast  beef,  the  white 
meat  of  fowls,  and  well-cooked  and  digestible  vegetables, 
especially  those  that  do  not  contain  too  much  saccharine 
or  starchy  matters.    Contrary  to  the  popular  idea,  we  are 
in  the  habit  of  forbidding  fruit,  especially  raw,  acid  fruit, 
to  acne  patients.     Cooked  fruit  is  less  objectionable.     If 
constipation  is  a  prominent  feature,  we  order  a  large  cup  of 
hot  water  to  be  slowly  sipped  one  hour  before  breakfast  and 
on  retiring  at  night.   The  addition  of  one-half  teaspoonful  of 
Carlsbad  salts  to  the  hot  water  in  the  morning  is  very  useful, 
even  where  there  is  no  constipation.    Only  enough  water 
should  be  drunk  at  meals  to  secure  mastication  of  the  food, 
and  on  no  account  should  a  meal  be  prefaced  with  a  goblet 

1  Bulkley  insists  that  in  order  to  get  proper  absorption  of  milk  it 
should  be  given  alone,  pure  or  diluted,  at  the  body  temperature  and 
at  the  conclusion  of  gastric  digestion;  that  is,  between  meals,  when 
the-  stomach  is  einptv.  Skin  Diseases  and  Internal  Disorders,  p. 
112  et  set]. 


ACNE  401 

of  iced  water.  It  is  well  to  drink  copiously  of  water  between 
meals,  and  especially  should  a  glassful  be  taken  about  two 
hours  after  a  repast.  An  action  of  the  bowels  should  be 
solicited  at  the  same  hour  every  day,  and  patients  should 
be  warned  not  to  read  while  at  stool.  Gentle  kneading  of 
the  bowel  in  the  direction  of  the  colon  at  this  time  is  also 
to  be  advised. 

It  is  needless  to  say,  that  as  regards  internal  treatment 
with  drugs,  we  have  no  specifics.  The  so-called  blood 
purifiers,  such  as  sarsaparilla  and  iodide  of  potassium,  are 
useless,  and  in  the  case  of  the  latter  positively  injurious. 

The  treatment  must  necessarily  be  symptomatic.  It 
should  be  our  care  to  seek  out  all  complications  and  remove 
them  if  possible.  Dyspepsia  and  constipation  are  to  be 
treated  on  general  principles,  if  anything  is  required  in 
addition  to  the  dietetic  and  hygienic  measures  outlined 
above.  Sometimes  in  plethoric  subjects,  when  there  is 
costiveness  and  a  coated  tongue  and  much  local  hyperemia, 
the  Mistura  ferri  acida  serves  a  good  purpose : 

1$ — Magnesii  sulphatis 3j 

Ferri  sulphatis gr.  iv 

Sodii  chloridi 6ss 

Acidi  sulphurici  diluti 3ij 

Infus.  gentianse q.  s.  ad  3iv — M. 

S. — A  tablespoonful  in  a  goblet  of  water,  one-half  hour  before 
breakfast. 

Another  method  of  overcoming  constipation  is  by  the 
administration  of  a  teaspoonful  of  common  salt  in  a  large 
glass  of  water  one-half  hour  before  breakfast.  In  obsti- 
nate cases,  especially  to  begin  with,  a  nightly  pill  of  aloin, 
strychnine,  and  belladonna  may  be  ordered.  When  the 
bowels  are  unusually  sluggish  the  pills  of  iron  and  aloes 
(aqueous  ext.  aloes,  1  gr. ;  and  sulphate  of  iron,  2  gr.), 
recommended  by  Spender,  will  be  found  valuable.  One 
such  pill  should  be  taken  three  times  a  day  at  first,  but 
afterward  the  dose  should  be  rapidly  diminished  until  one 
every  few  nights  will  be  found  sufficient.  Cascara  sagrada 
and  rhamnus  frangula  are  also  of  value.  The  routine 
administration  of  decided  purgatives  is,  however,  very  bad 
26 


402        DISEASES  OF  THE  SEBACEOUS  GLANDS 

practice,  and  so  soon  as  the  bowels  have  been  properly 
opened,  it  is  best  to  try  to  keep  up  the  regularity  by  the 
simpler  methods  first  mentioned.  In  the  anemic,  iron  is 
indicated.  Some  one  of  the  numerous  organic  compounds 
of  iron  with  albumin  may  be  given  as  less  prone  to  disturb 
the  digestion. 

The  malt  extracts  and  cod-liver  oil  are  also  suitable 
remedies  in  weakly  young  people,  who  have  greasy  skins, 
and  suffer  from  cold  hands  and  feet,  or  are  of  the  so-called 
scrofulous  habit. 

An  emulsion  made  in  the  following  way  is  very  eligible : 

3$ — Olei  morrhuae 5jv 

Pancreatini  saccharati 5j 

Pulv.  acacise q.  s. 

Glyceriti  hypophosphitis, 
Syr.  calcis  lactophosphatis, 

Aquse aa  5iv 

Olei  gaultheriae gtt.  xxx — M. 

S. — A  tablespoonful  three  times  a  day,  after  meals. 

When  the  acne  is  accompanied  by  considerable  hyper- 
emia  and  irritability  of  the  skin,  Taylor  recommends  that 
alkalies  be  given  for  periods  of  two  or  three  months : 

1^ — Potassii  acetatis 5j 

Sodii  et  potass,  tart §ij 

Syr.  zingiberis §ij 

Aquae q.  s.  ad  gviij — M. 

S. — A  tablespoonful  in  a  wineglassful  of  water,  after  meals. 

Bulkley  speaks  highly  of  the  following  mixture  given  in 
acne  indurata: 

!fy — Potassii  acetatis §ss-3j 

Tr.  nucis  vomicse 3ij 

Extracti  rumicis  fld f  5iv — M. 

S. — A  teaspoonful  in  water,  half  an  hour  before  eating. 

Where  there  is  constipation,  the  same  authority  recom- 
mends the  addition  of  20  or  30  drops  of  the  fluidextract 
of  cascara  sagrada  to  each  dose,  and  if  there  be  menstrual 
disturbance  a  further  addition  of  10  to  20  drops  of  the 
tincture  of  cypripedium. 

In  certain  chronic  cases  minute  doses  of  the  bichloride 


ACNE  403 

of  mercury  (gr.  3^)  with  tincture  of  cinchona  bark  may 
be  tried.  Menthol,  1  or  2  gr.  after  meals,  is  a  favorite 
remedy  with  Whitfield. 

Arsenic  has  been  an  almost  routine  prescription  with 
many  physicians  in  the  treatment  of  acne.  In  the  form  of 
the  bromide  of  arsenic  in  combination  with  the  chloride 
of  gold,  we  believe  we  possess  a  remedy  of  considerable 
value  in  suitable  cases. 

1^ — Arsenici  brpmidi 3ss 

Aurii  chloridi gr.  xv 

Acidi  nitrohydrochlorici nyd 

Aquae  destillatae 5vij — M. 

S. — Dissolve  the  arsenic  bromide  in  the  acid;  add  the  water  and 
gold  chloride  with  a  few  drops  of  bromine  to  make  a  clear  solution. 

The  dose  of  this  preparation  is  from  8  to  10  drops  in 
one-half  glass  of  water  directly  after  meals.  It  is  well, 
however,  to  begin  with  3  drops  and  gradually  to  increase 
to  10  drops. 

The  sulphide  of  calcium  sometimes  acts  well  in  pustular 
acne  and  in  acne  indurata.  So  far  as  we  have  observed, 
its  influence  is  limited  to  the  prevention  of  undue  suppura- 
tion, but  it  does  not  seem  to  exert  any  permanently  curative 
effect. 

It  should  be  given  in  the  shape  of  gelatin-coated  pills, 
and  in  the  dose  of  ^  to  \  gr.,  three  or  four  times  a  day. 
Payne  believes  that  sulphur  taken  internally  is  often  very 
beneficial. 

The  fluidextract  of  ergot  in  |-drachm  doses,  three 
times  a  day,  is  occasionally  useful,  and  again  appears  per- 
fectly inoperative.  We  have  not  found  the  internal  use  of 
ichthyol  of  any  advantage.  It  has  been  claimed  that  in  the 
acne  of  young  men  due  to  sexual  causes  great  relief  has 
been  produced  from  the  passage  of  cold  sounds  into  the 
urethra,  also  that  hot  vaginal  douches  have  been  equally 
successful  with  young  women. 

The  so-called  "opsonic"  treatment  (A.  E.  Wright),  that 
is  to  say,  with  antistaphylococcal  vaccine  injections,  is 
plausible  in  theory  and  probably  will  be  valuable  in 


404        DISEASES  OF  THE  SEBACEOUS  GLANDS 

practice  in  certain  conditions,  but  to  the  general  physician 
the  difficulty  of  its  application  will  perhaps  prove  a  bar  to 
such  utility  as  it  may  possess.  Further  details  on  this 
subject  may  be  found  in  Part  II. 

The  judicious  local  treatment  of  acne  is  of  the  greatest 
importance.  The  topical  measures  to  be  employed  will 
depend  largely  upon  the  character  of  the  disease  present. 
As  in  all  diseases  of  uncertain  prognosis,  there  is  an  embar- 
rassment of  riches  in  the  way  of  remedies,  although  in 
reality  the  therapeutic  indications  are  relatively  simple. 
The  management  of  comedo,  acne  punctata,  has  already 
been  considered  (vide  ante},  but  as  common  acne  is  due 
to  and  connected  with  the  presence  of  comedones  on  the 
skin,  some  repetition  is  unavoidable. 

In  acne  vulgaris  or  inflammatory  acne  it  is  often  advis- 
able to  delay  active  treatment  for  a  season  and  order 
simple  soothing  lotions  or  salves,  such  as  the  following: 

!ty — Acidi  borici 9ij 

Zinci  oxidi 5ij 

Pulv.  calaminae  praep 9ij 

Glycerini 3ij-3iv 

Aquae  rosae q.  s.  ad  5iv — M. 

S.— Shake.    External  use. 

1$ — Bismuthi  subnitratis 5ij 

Acidi  hydrocyanici  diluti 3j 

Glycerini oij 

Aquam  rosam ad  3iv — M. 

S. — Local  use. 

In  slight  cases  a  powder  of  precipitated  sulphur  diluted 
with  2  or  3  parts  of  rice  powder  is  often  of  advantage. 

Another  method  in  a  similar  class  of  cases,  and  which 
we  have  found  very  satisfactory,  is  the  use  of  boric  arid 
as  recommended  by  Post: 

1^ — Acidi  borici oiv 

Alcoholis Sviij — M. 

S. — Shake  and  apply  several  times  a  day,  or  whenever  the  skin  is 
oily.  Wash  the  face  at  night  with  a  sulphur  soap. 

In  the  great  majority  of  cases  of  acne,  however,  active 
measures  are  called  for  from  the  first.  All  comedones 


ACNE  405 

should  be  thoroughly  but  gently  expressed  with  a  comedo 
spoon,  preferably  of  the  Piffard  type;  papules  and  pustules 
should  be  stabbed  with  an  acne  lancet  and  allowed  to 
bleed  freely,  and  the  bleeding  may  be  encouraged  by 
fomentations  with  warm  water.  It  is  even  well  to  prick  the 
papules  as  soon  as  they  appear,  since  their  course  is  thereby 
much  shortened.  Fox  and  Jackson  strongly  recommend 
going  over  the  surface,  previously  put  on  the  stretch,  with 
a  blunt  dermal  curette,  tearing  off  the  tops  of  papules  and 
pustules,  thus  allowing  the  easier  extrusion  of  the  follicular 
contents,  and  stimulating  the  skin  to  a  healthier  action. 
This  operation  may  be  repeated  two  or  three  times  a  week. 
Twenty-four  hours  after  the  scraping,  Jackson  employs  a 
sulphur  ointment,  1  drachm  to  1  oz.,  or  a  bichloride  wash, 
J  gr.  to  1  oz.  of  alcohol,  or  the  Kreuznach  soap,  No.  2. 

Indurated  nodules  and  cutaneous  abscesses  must  be 
opened  with  a  free  hand.  After  the  employment  of  any  of 
these  harsh  mechanical  methods  the  patient  should  foment 
the  parts  for  a  few  minutes  with  cloths  wrung  out  in  hot 
water,  and  afterward  mop  on  a  soothing  lotion. 

It  is  not  always  easy  to  gain  the  consent  of  patients  to 
this  undoubtedly  valuable  but  rough-shod  method  of 
procedure,  and  the  physician  must  at  times  content  himself 
with  the  absolutely  necessary  expressing  of  black  heads, 
and  the  incision  of  such  pustules  and  nodules  as  urgently 
require  it. 

In  cases  of  moderate  severity,  frictions  with  green  soap 
or  the  tincture  of  green  soap  are  very  useful,  and  with 
timid  persons  may,  to  a  certain  extent,  supplement  the 
lancet  or  curette. 

1^ — Saponis  viridis, 

Alcoholis aa    3j 

Aqiur  rosse 3vj — M. 

8. — Rub  in  with  a  piece  of  flannel  at  night. 

After  a  few  days  a  slight  dermatitis  will  be  set  up  and  a 
certain  amount  of  desquamation  occur;  when  this  happens 
the  scrubbings  may  be  intermitted  and  cold  cream  applied. 
For  the  same  purpose  Norman  Walker  prescribes  a  sulphur, 


406        DISEASES  OF  THE  SEBACEOUS  GLANDS 

camphor,  and  balsam  of  Peru  soap  (Eichhoff),  and  offers 
the  following  practical  suggestions  for  its  employment. 

With  a  shaving  brush  an  abundant  lather  is  produced, 
which  is  rubbed  in  for  a  few  minutes.  For  the  first  few 
days  it  is  wiped  off  with  a  damp  cloth,  but,  later,  when  the 
skin  becomes  tolerant  to  it,  the  lather  may  be  more  and 
more  thoroughly  worked  in  until  eventually  there  is  none 
left  to  remove.  As  the  skin  will  finally  rebel  against  these 
frictions,  one  night  in  a  week  the  skin  may  be  simply 
anointed  with  cold  cream  or  vaselin. 

Without  doubt  one  of  the  most  efficacious  methods  of 
treating  acne  indurata  is  by  the  Vleminckx  solution : 

1$ — Calcis      .          5ss 

Sulphuris  sublimati 3j 

Aquae 5x — M. 

Boil  down  to  six  ounces  and  filter. 

In  acne  of  the  back  this  solution  may  be  used  diluted 
one-half  with  water  at  first,  and  then,  after  tolerance  is 
established,  of  full  strength.  We  are  indebted  to  C. 
Heitzmann  for  directions  as  to  its  systematic  employment 
in  acne  of  the  face.  Before  the  use  of  the  solution  is  com- 
menced, some  time — in  severe  cases  several  weeks — should 
be  consumed  in  getting  rid  of  flesh-worms  by  inunctions 
with  strong  lather  of  green  or  castile  soap;  also  during 
the  treatment  the  emptying  of  comedones  must  be  kept  up 
and  continued  from  time  to  time  to  prevent  relapses,  and 
all  lesions  must  be  incised.  The  preparatory  treatment 
having  been  accomplished,  the  patient  is  directed  to  com- 
mence with  the  solution  in  the  strength  of  one  teaspoonful 
to  five  of  water;  after  three  or  four  days  he  will  take  one 
to  four  and  one-half  of  water;  then  one  to  four,  and  so  on 
with  one  teaspoonful  less  of  water  every  fourth  night  until 
the  remedy  comes  to  be  used  pure.  Sometimes  the  solution 
cannot  be  pushed  to  its  full  strength,  and  the  result  is 
obtained  with  dilutions  of  one,  one-half,  one-third,  or  less; 
or  it  may  be  that,  instead  of  increasing  the  strength  every 
fourth  night,  we  must  pause  at  a  given  dilution  for  a  week 
or  more,  and  .hen  proceed  gradually.  The  remedy  should 


ACNE  407 

be  merely  mopped  on  at  first;  and  afterward,  if  it  is 
tolerated,  rubbed  in  more  firmly.  If  much  dermatitis  is 
set  up,  a  little  cold  cream  may  be  smeared  on  during  the 
day,  or  the  applications  may  be  intermitted  for  a  short 
while. 

What  is  called  the  "shelling  method"  accomplishes  much 
more  quickly  the  desquamation  of  the  skin  that  is  sought 
by  the  slower  process  described  above.  This  process  has 
the  disadvantage  that  the  patient  is  confined  to  the  house 
during  its  progress,  and  occasionally  more  serious  incon- 
veniences may  ensue.  We,  nevertheless,  recommend  it 
highly  when  the  consent  of  the  patient  can  be  gained  after 
a  frank  statement  of  its  unpleasant  features.  The  following 
pastes  are  usually  employed  for  this  purpose: 

1$ — Resorcini 5ss 

Zinci  oxidi 3j 

Terras  siliceae gr.  xij 

Adipis  benzoati q.  s.  ad  5j — M. 

S. — Apply  to  the  face  spread  upon  lint.  Unna. 

This  may  be  kept  on  for  twenty  or  thirty  minutes,  then 
washed  off  with  warm  water,  and  a  cold  cream  applied,  or 
talcum.  The  paste  may  be  put  on  nightly,  or,  if  quicker 
action  is  desired,  two  or  three  times  a  day. 

Lassar's  preparation  is  as  follows : 

]$ — Naphtholis gr.  xxxv 

Sulphuris  prsecipitati 3iij 

Vaselini, 

Saponis  viridis aa  3jss — M. 

This  is  to  be  spread  upon  the  skin  to  the  thickness  of 
the  back  of  a  knife-blade,  and  left  on  for  fifteen  or  twenty 
minutes,  when  it  will  cause  a  little  burning.  It  is  then  to  be 
wiped  off  with  a  soft  cloth,  and  the  skin  powdered  with  talc. 
The  paste  may  be  repeated  daily.  The  skin  soon  becomes 
inflamed,  then  turns  brown,  and  finally  peels  off.  The 
desquamation  can  be  hastened  by  the  application  of 
Lassar's  paste  with  2  per  cent,  of  salicylic  acid.  When  the 
desquamation  has  ceased,  the  acne  will  be  found  to  be 
greatly  benefited. 


408        DISEASES  OF  THE  SEBACEOUS  GLANDS 

Stel wagon  advises,  for  the  same  purpose,  a  25  to  50  per 
cent,  alcoholic  lotion  of  resorcin,  which  may  be  mopped  on 
two  or  three  times  a  day. 

The  same  author  recommends  formaldehyde  solution 
for  the  back,  using  it  in  sufficient  strength  to  produce 
considerable  irritation;  afterward  a  boric  acid  powder 
may  be  dusted  over  the  surface.  The  underclothing 
should  be  frequently  changed. 

In  many  cases  of  acne,  in  which  the  more  active  measures 
just  described  cannot  be  carried  out,  or,  from  the  nature 
of  the  condition  present,  are  not  indicated,  good  results 
may  be  often  obtained  by  other  means. 

Chief  among  the  remedies  stands  sulphur,  and,  perhaps, 
the  most  generally  useful  method  of  its  application  is  in  the 
form  of  the  lotio  alba: 

1$ — Zinci  sulphatis, 

Potassii  sulphureti aa  gr.  xxx-5ij 

Aquae  rosse 5iv — M. 

S. — Shake  well.    Apply  daily. 

The  resulting  mixture  should  be  of  a  white  color  and  not 
brown  or  black  as  usually  dispensed.  The  strength  of 
the  mixture  must  depend  upon  the  condition  of  the  skin  to 
be  treated,  the  usual  prescription,  however,  being  1  drachm 
of  each  of  the  salts  to  4  oz.  of  water.  Sometimes  it  is  well 
to  add  a  little  glycerin,  3  to  4  minims  to  1  oz.,  to  relieve 
the  harshness  of  the  skin  that  the  lotion  produces.  To 
increase  the  stimulating  quality  of  the  mixture  in  sluggish 
cases,  1  drachm  of  sulphur  may  be  added. 

Other  preparations  of  sulphur  in  lotion  form  are  as 
follows : 

1$ — Sulphuris  praecipitati 3j 

Alcoholis oiv 

^Etheris 5iijss — M. 

S. — Shake.    Apply  at  night  and  once  or  twice  during  the  day. 

1$ — Sulphuris  loti 5iij 

Spt.  camphorae oiij 

Sodii  biboratis oij 

Glycerini 5vj 

Aquse q.  s.  ad  3iv — M. 

S. — Shake  the  bottle  and  apply  freely. 


ACNE  409 

1$ — Sulphuris  prsecipitati 3ij 

Pulv.  camphorse gr.  x 

Pulv.  tragacanthse gr.  xx 

Liq.  calcis, 

Aquae  rosae aa     3ij — M. 

S. — Shake.     External  use.  Kummerfeld. 

This  last  prescription  is  especially  useful. 

Ointments  are  also  advised  in  the  treatment  of  acne, 
but  they  are  not  so  serviceable  as  liquid  preparations.  They 
should  be  thoroughly  worked  into  the  skin: 

1$ — Sulphuris  hypochloridi 3ij 

Potassii  carbonatis gr.  x 

Adipis  benzoati 3j 

Olei  amygdalae  amarae gtt.  ij— M. 

S. — Rub  in  a  small  quantity  at  night.  Wilson. 

The  following  is  a  very  acceptable  preparation : 

1$ — Sulphuris  praecipitati 3j 

Ung.  aq.  rosae 3j — M. 

S. — Apply  at  night. 

Ointments  of  the  various  mercurial  preparations  have 
been  prescribed  for  cases  needing  active  stimulation,  e.  g., 
proto-iodide  of  mercury  (5  to  10  gr.  to  1  oz.),  and  the 
white  precipitate  (20  to  30  gr.  to  1  oz.). 

Lotions  containing  mercury  are  occasionally  of  service: 

R — Hydrarg.  bichloridi gr.  j 

Tr.  benzoini 5ij 

Mist,  amygdalae §vj — M. 

S. — Apply  lukewarm. 

To  the  sluggish  liodules  of  acne  indurata  we  are  in  the 
habit  of  applying  Unna's  salve  muslin  of  mercury  and 
carbolic  acid. 

Hutchinson  touches  lesions  as  they  appear  with  a  small 
quantity  of  the  acid  nitrate  of  mercury.  W.  G.  Smith 
prefers  the  pure  carbolic  acid,  afterward  covering  the 
spot  with  a  film  of  collodion.  Faradization  of  the  face  with 
a  sponge  electrode — the  positive  pole  to  the  nape  of  the 
neck  and  the  negative  to  the  aft'ected  parts — is  often  very 
useful.  The  applications  are  to  be  kept  up  for  ten  or 


410         DISEASES  OF  THE  SEBACEOUS  GLANDS 

fifteen  minutes,  at  intervals  of  a  few  days.  We  do  not 
think  so  well  of  galvanism. 

The  high-frequency  current  has  taken  the  place,  in  our 
hands,  of  the  faradic  and  galvanic  currents,  and  is  undoubt- 
edly more  efficient.  It  should  be  applied  by  means  of  the 
hammer  electrode  held  about  one-quarter  of  an  inch  from 
the  face,  and  continued  sufficiently  long  to  produce  a  slight 
reddening  of  the  skin. 

Pospelow  and  Jackson  strongly  recommend  massage. 
According  to  the  first-named  authority  the  rubbing  should 
follow  the  direction  of  the  gland  ducts  and  muscle  fibers  of 
the  skin  in  order  that  the  sebum  may  be  expressed  from 
the  glands.  It  should  be  employed  for  ten  minutes  at  a 
time,  morning  and  evening,  and  kept  up  for  several  months. 
Hyde's  ingenious  "massering  ball"  may  also  be  employed 
in  this  connection. 

The  x-ray,  in  the  opinion  of  many  practitioners,  is  the 
best  agent  at  our  command  in  the  treatment  of  acne. 
Torok  and  Schein  consider  it  the  most  reliable  of  any 
treatment  known.  While  we  hold  that  many  of  the  older 
forms  of  treatment  are  too  valuable  to  be  abandoned,  and 
that  some  cases  of  acne  cannot  be  cured  by  the  rays  alone, 
we  are  ready  to  admit  that  no  one  procedure  is  so  generally 
of  benefit  as  the  use  of  the  rays. 

The  best  results  are  obtained  with  a  soft  tube  and  a  very 
faint  light,  such  as  shows  the  soft  tissues  of  the  hand  black 
against  a  dimly  lighted  screen.  It  is  difficult  to  believe  that 
an  agent  apparently  so  weak  can  have  much  effect,  until 
one  has  witnessed  a  demonstration  of  the  fact.  This  effect 
is  produced  in  several  ways:  by  an  increased  leukocytosis; 
by  increased  lymph  supply,  thus  raising  the  local  opsonic 
index;  by  bringing  about  a  vascular  constriction,  and  by 
gradually  producing  an  atrophy  of  the  sebaceous  glands. 
Pusey  believes  in  a  bactericidal  effect  as  well.  Eight- 
minute  sittings  at  8  inches  may  be  given  three  times  a  week. 
Stelwagon  is  more  cautious  and  advises  sittings  of  three  to 
four  minutes,  three  times  a  week,  at  10  to  15  inches  dis- 
tance. He  apparently  uses  a  stronger  light  than  we  advise. 


ACNE  411 

If  erythema  appears,  sittings  should  be  at  once  discon- 
tinued. The  danger  of  producing  atrophy  must  not  be 
forgotten.  The  eyes  should  be  shielded  by  spectacle  frames 
covered  with  sheet-lead,  with  side  blinkers  of  the  same 
material.  The  scalp  must  also  be  protected. 

Leredde  and  Belot  speak  well  of  phototherapy. 

Reports  from  the  Finsen  Institute  show  cure  of  one-half 
the  cases  treated. 

Among  the  new  suggestions,1  in  the  management  of 
this  disorder,  may  be  mentioned  the  cylindrical  punch  of 
Kromayer,  which  is  a  device  for  removing  minute  pieces 
of  skin  containing  the  affected  glands.  It  is  in  effect  a 
Keyes  punch  operated  by  a  motor  or  dental  engine. 
Another  plan  of  treatment  (Moschkowitz)  is  the  use  of  dry 
cups  to  the  parts  affected  for  one-half  hour  once  or  twice  a 
day,  employing  slight  suction  only  and  permitting  each  cup 
to  remain  in  position  for  one  or  two  minutes.  (See  article 
on  Passive  Hyperemia,  Part  II.)  Stelwagon  in  his  text- 
book recommends  going  over  the  face  with  a  small  cupping 
glass — about  1  inch  opening — and  speaks  of  the  method 
as  very  satisfactory. 

ADDITIONAL  PRESCRIPTIONS. 

]$ — Sulphuris  praecip 3j 

Calaminae 5ij 

Zinci  oxidi 5iij 

Glycerini 3j 

Aquae  destillatae q.  s.  ad  5iv — M. 

S. — Shake  and  apply  with  a  brush.  Walker. 

1$ — Sulphuris  sublimat 5ij 

^Etneris, 
Alcoholis, 

Glycerini aa    5ij 

S  Liq.  calcis, 

Aquae  rosae aa    5iv — M. 

Crocker. 

1$ — Sulphuris  prsecip Sijss 

Alcoholis 5jss 

Spt.  layandulae 3iij 

Glycerini 5ss — M. 

Hebra. 

1  Quoted  by  Gottheil  in  Progressive  Medicine. 


412         DISEASES  OF  THE  SEBACEOUS  GLANDS 


—  Resorcini       ..........      Sss-  3ij 


Acidi  borici 
Zinci  sulphatis 
Alcoholis 
Aq.  destillatae 
S.  —  External  use. 

1$  —  Adipis  lanae 

Acidi  acetici  diluti 
Adipis  benzoati 
Sulphuris  praecip 

S.  —  External  use. 


q.  s.  ad 


3j- 

gr.  xx-xxx 

3ss 

5iv  —  M. 

Stelwagon. 

Sijss 


gr.  xl  —  M 
Unna. 


1$  —  Bismuthi  subnitratis, 
Hydrarg.  ammoniati, 
Ichthyolis     .      .      .      ......   aa     gr.  xxx 

Vaselini  ...........      Sv  —  M. 

S.  —  Apply  thickly  before  bedtime.  Hebra-Ullmann. 

1$  —  Sulphuris  prsecip  .........     3j 

Pulv.  camphorae      ........     gr.  xx 

Ung.  aquae  rosae, 

Vaselini  .......  .   aa    Siv  —  M. 

Van  Harlingen. 

.  .  Siv 
3x 
Svj 

3j  —  M. 
Elliott. 

Sss 
rt\xxx 


1$  —  Sulphuris  praecip 
Tr.  sappnis  viridis 
Glycerini 
Alcoholis 


1$  —  Sulphuris  pra?cip 

Glycerini 

Spt.  camphoraj 

Liq.  calcis 
S.  —  External  use. 

1$  —  Zinci  oxidi 

Ichthyolis 

Sulphuris  pra?cip 

Ol.  lavandulae 

Pulv.  amyli 

Vaselini 
S.  —  Apply  as  a  paste. 


q.  s.  ad 


q.  s.  ad 


3j  —  M. 

Payne. 

5j 

gtt.  xx 
DBS 
gtt.  iv 
Siij 

3j  —  M. 
Wolff. 


ACNE  ROSACE  A  413 


ACNE  ROSACEA. 

Description. — This  is  a  chronic,  hyperemic  or  inflamma- 
tory affection  of  the  skin,  occupying  principally  the  region 
of  the  face,  and  more  especially  the  nose,  cheeks,  chin,  and 
forehead.  We  have  also  seen  it  well  marked  on  the  neck. 
The  prominent  clinical  features  are  redness,  papulation, 
and  pustulation,  the  appearance  of  dilated  bloodvessels, 
and  sometimes  an  excessive  new  formation  of  connective 
tissue. 

It  is  customary  to  divide  the  disease  into  three  stages, 
but  one  stage  does  not  necessarily  follow  the  other. 

Generally,  simple  hyperemia  is  first  observed;  later  on 
the  congestion  becomes  permanent;  the  vessels  dilate,  the 
skin  is  thickened,  and  a  secondary  acne  supervenes;  finally, 
but  by  no  means  in  all  cases,  or  even  in  the  majority,  the 
morbid  process  advances  a  step  farther,  and  decided  hyper- 
trophic  changes  occur,  and  the  parts  involved,  particularly 
the  nose,  will  assume  a  lobulated  and  hob-nailed  appear- 
ance, and  in  aggravated  cases  broad  bands  and  peduncu- 
lated  red  tumors  of  the  size  of  the  fist  may  be  formed 
(Rhinophyma). 

The  clinical  picture  presented  in  rosacea  varies  a  good 
deal  in  different  cases,  and  from  time  to  time  in  the  same 
case.  A  form  of  the  disease  is  common  in  ill-conditioned 
young  people  in  whom  there  is  simple  redness  of  the  skin, 
with  a  cold  surface,  and  more  or  less  accompanying  sebor- 
rhea.  Here  the  nose  is  the  common  site  of  the  disorder. 

In  another  class  of  cases  the  degree  of  hyperemia  changes 
from  day  to  day  or  from  hour  to  hour;  sometimes  the  face 
is  all  aflame,  and  again  almost  normal,  or  there  is  much 
complaint  of  burning  and  even  slight  itching.  Sometimes 
the  vascular  dilatation  is  the  most  prominent  element  in 
the  case,  and  there  will  be  little  or  no  intervening  hypeiviiiia 
of  the  skin.  A  common  seat  of  rosacea  in  women  is  upon 
the  chin. 

The  causes  of   acne    rosacea    are   numerous.     Among 


414        DISEASES  OF  THE  SEBACEOUS  GLANDS 

the  more  common  are  menstrual  irregularities,  anemia, 
chlorosis,  dyspepsia,  constipation,  the  gastric  catarrh  of 
drinkers,  and  exposure  to  excessive  heat  or  cold. 

A  recurrent  inflammation  of  the  hair  follicles  just  inside 
the  nose  is  a  not  uncommon  cause  of  a  chronic  redness  at 
the  end  of  that  organ.  Chronic  nasal  disease  and  conditions 
that  interfere  with  the  local  circulation  must  also  be  taken 
into  account.  In  men  rosacea  is  most  frequent  after  forty 
years  of  age,  although  not  uncommon  in  quite  young  men ; 
and  in  women  it  is  most  apt  to  supervene  at  puberty  or  at 
the  menopause.  The  disorder  is  nearly  always  a  reflex  one. 
Its  initial  stage  is  caused  by  prolonged  or  often  repeated 
stasis  in  the  capillaries,  and  all  the  subsequent  pathological 
changes  find  their  explanation  in  this  fact.  Unna  urges 
that  the  prefix  "acne"  should  be  dropped  entirely,  for  that 
rosacea  is  in  19  out  of  20  cases  seborrheic,  and  only  rarely 
an  angioneurosis,  and  that  this  latter  condition  never  leads 
to  hypertrophy. 

As  a  rule,  the  diagnosis  presents  few  difficulties.  Acne 
rosacea  should  be  differentiated  from  simple  acne,  lupus 
erythematosus,  lupus  vulgaris,  and  the  tubercular  syphi- 
lide. 

Prognosis. — The  prognosis  in  cases  of  mild  grade  is 
generally  favorable,  and  even  where  the  disease  has  existed 
for  a  long  time,  if  the  cause  can  be  ascertained  and  removed, 
gratifying  results  may  be  obtained.  On  the  other  hand, 
palliation  is  frequently  all  that  can  be  promised. 

Treatment. — The  treatment  is  both  internal  and  local. 
The  cause  or  causes  of  the  disease  should  be  diligently 
sought  and  removed  if  possible.  The  same  general  rules 
as  to  diet  and  hygiene,  mentioned  in  connection  with  acne, 
are  equally  applicable  here. 

In  chronic  gastric  catarrh,  Carlsbad  salts,  one  tea- 
spoonful  in  a  goblet  of  hot  water  taken  one  hour  before 
breakfast,  and  10  gr.  each  of  carbonate  of  magnesium  and 
subcarbonate  of  bismuth  after  meals,  may  be  given  with 
advantage.  Lavage  of  the  stomach  is  also  useful  in  some 
cases.  Ichthyol  in  3-  to  6-minim  doses,  in  pill  or  capsule, 


ACNE  ROSACE  A  415 

is  also  advised.  We  have  seen  marked  improvement  from 
its  use.  Dyer  obtained  a  good  result  in  a  case  of  hyper- 
trophic  rosacea  from  the  administration  of  thyroid  extract. 
Topically,  the  applications  should  be  suitable  to  the  stage 
of  disease  present.  In  the  hyperemic  stage  ointments  and 
lotions  of  sulphur  and  mercury  are  indicated.  (See  Acne.) 
Kummerfeld's  lotion  is  recommended  by  Van  Harlingen: 

1$ — Sulphur,  prsecipitati 3j 

Pulv.  camphorae gr.  v 

Pulv.  tragacanthae gr.  x 

Aquae  rosae, 

Liq.  calcis aa  5j — M. 

S. — Apply  once  or  twice  a  day. 

In  cases  of  the  second  degree  all  pustules  should  be 
opened,  tubercles  freely  incised,  and  the  invaded  region 
should  be  fomented  with  hot  water  several  times  a  day. 
The  best  local  application  in  our  experience  is  Vleminckx's 
solution,  which  should  be  employed  in  the  manner  described 
under  the  treatment  of  acne.  We  have  derived  benefit 
from  daily  painting  with  the  1  to  1000  adrenalin  chloride 
solution. 

The  best  method  of  destroying  the  varicose  vessels  is  by 
electrolysis,  as  first  suggested  by  one  of  us  many  years  ago.1 

A  fine  jeweller's  bristle  or  dental  reamer  is  attached  to  the 
negative  pole  electrode  of  a  galvanic  battery  (by  means  of 
a  suitable  holder)  and  the  needle  is  inserted  into  the  vessel 
for  a  sufficient  depth;  the  circuit  is  then  closed  by  the 
patient  touching  the  positive  sponge  electrode  with  the 
tips  of  the  fingers,  or,  better  still,  by  placing  one  or  more 
fingers  in  a  bowl  of  water  in  which  this  pole  has  been 
placed;  after  the  electrolytic  action  has  been  developed, 
as  shown  by  the  vessel  becoming  a  white  line,  the  fingers 
are  removed  from  the  positive  sponge  electrode,  after  which 
the  needle  is  withdrawn  from  the  tissues. 

Sometimes  one  puncture  is  sufficient  for  obliteration, 
but  if  the  vessel  is  long,  several  insertions  may  be  made 
along  its  course.  If  the  operation  is  carefully  done,  no 

1  Hardaway,  Archives  of  Dermatology,  October,  1879. 


416         DISEASES  OF  THE  SEBACEOUS  GLANDS 

scarring  need  result.  It  is  true  that  a  collateral  circulation 
is  often  set  up  and  the  operation  must  be  repeated;  but 
in  cases  where  the  cause  of  the  disease  has  been  removed 
we  have  seen  permanent  results.  In  the  mean  time  the 
improvement  in  the  patient's  appearance  is  very  note- 
worthy. The  strength  of  current  employed  will  depend 
somewhat  upon  the  locality  operated  upon,  the  size  of  the 
vessels,  etc.  It  is  probably  best  in  various  electrolytic 
operations  on  the  skin  to  employ  a  milliamperemeter,  but 
it  is  not  absolutely  necessary. 

Various  other  methods  of  treating  rosacea  have  been 
recommended.  In  cases  of  a  marked  type  many  employ 
some  form  of  multiple  puncture  or  scarification.  Vidal 
speaks  highly  of  what  he  calls  linear  quadrilateral  scarifi- 
cations. Shoemaker  uses  a  needle-knife  with  which  he 
makes  numerous  punctures,  while  at  the  same  time  he 
constantly  applies  hot  or  very  warm  water.  Kaposi  advises 
a  solution  of  iodated  glycerin  (5  parts  each  of  pure  iodine 
and  the  iodide  of  potassium  to  10  of  glycerin),  which  is 
painted  over  the  affected  region  eight  to  twelve  times  a  day 
for  three  or  four  successive  days,  and  immediately  covered 
with  gutta-percha  paper.  Carbolic  acid,  1  in  2  to  6  of 
alcohol,  is  said  to  be  useful  by  Duhring.  Abraham  recom- 
mends, in  the  first  two  grades  of  rosacea,  the  subcutaneous 
injection  of  95  per  cent,  alcohol.  Not  more  than  30  drops 
of  the  fluid  are  required,  and  the  injections  should  not  be 
made  oftener  than  three  times  a  week.  Excellent  results 
are  claimed  if  strict  antiseptic  precautions  are  observed. 
Others  advise  the  local  application  of  absolute  alcohol 
several  times  daily. 

When  redness  of  the  nose,  usually  of  the  end  of  the  organ, 
is  due  to  inflammation  of  the  hair  follicles  just  within  thr 
nares,  it  is  advisable  to  pluck  the  hairs  and  to  keep  a  10 
per  cent,  ointment  of  xeroform  or  some  similar  preparation 
constantly  applied.  General  tonic  treatment  (one  or  two 
teaspoonfuls  of  a  mixture  of  equal  parts  of  the  glycerole  of 
the  hypophosphites  and  syrup  of  the  lactophosphatc  of 
lime)  is  also  helpful. 


ACNE  VARIOLIFORMIS  417 

The  X-rays. — The  technique  is  similar  to  that  used  in  acne 
vulgaris.  Marked  paling  of  affected  areas  and  lessening 
of  telangiectases  have  been  observed. 

The  high-frequency  current  is  often  valuable.  Galvan- 
ism has  been  used. 

In  the  hypertrophic  variety  of  rosacea  with  production  of 
excessive  outgrowth  of  tissue,  ablation  by  the  knife  is  the 
only  remedy.  We  have  relieved  moderate  degrees  of  thick- 
ening with  electrolysis,  plunging  the  needle  quite  freely 
into  the  tissues  in  various  directions. 

Multiple  applications  of  the  microcautery  have  been 
recommended. 

Finsen,  Leredde  and  Pautrier  report  results  with  photo- 
therapy second  only  to  those  obtained  in  lupus.  Thus  the 
former  had  good  results  in  13  out  of  25  cases,  and  the  latter 
in  all  of  6  cases.  Allen  says  that  long-lasting  redness  of  the 
nose  and  cheeks  which  electrolysis,  scarification,  and  the 
scaling-off  method  have  failed  to  relieve,  may  often  be 
cured  by  persistent  light  treatment,  with  disappearance  of 
dilated  vessels  and  varicosities. 


ACNE  VARIOLIFORMIS. 

Description. — This  comparatively  rare  and  little  under- 
stood affection  has  been  variously  termed  acne  necrotica, 
acne  varioliformis,  acne  atrophica,  lupoid  acne,  acne 
pilaris,  acne  atrophique,  etc. 

According  to  Stelwagon,  the  various  cases  described  as 
acnitis,  folliclis,  necrosing  folliculitis,  impetigo  rodens,  etc., 
are  related  to  this  disease,  or  are  anomalous  types  of  it. 
He  also  would  include  in  this  class,  clinically,  at  least, 
acne  agminata,  the  folliculitis  exulcerans  serpiginosa  nasi, 
and  the  acne  telangiectodes  of  Kaposi.  Unna's  ulerythema 
acneiforme  is  also  believed  to  belong  to  this  group. 

The  primary  lesion  in  acne  varioliformis  is  a  papule 
from  lentil  to  bean  size,  reddish  brown  in  color,  firm  to  the 
touch,  with  the  summit,  especially  in  lesions  on  the  scalp, 
27 


418        DISEASES  OF  THE  SEBACEOUS  GLANDS 

generally  pierced  by  a  hair.  In  a  few  days  the  apex  of 
the  lesion  presents  a  yellow,  waxy  appearance  from  which 
develops  a  yellow  or  brown  crust,  which,  in  three  weeks  or 
longer,  falls  off,  leaving  a  depressed,  supple  scar  suggestive 
of  the  pit  of  smallpox. 

The  seats  of  predilection  of  the  eruption  are  the  brow, 
the  anterior  border  of  the  scalp,  the  temples,  behind  the 
ears,  and  on  the  neck;  more  rarely  the  affection  may 
attack  the  trunk  and  the  extremities.  Unna  says  that  there 
is  a  superficial  and  a  deep  form,  the  latter  originating  in 
the  former.  Sometimes  the  lesions  occur  in  large  numbers, 
and  as  the  disorder  pursues  a  chronic  course,  the  disease 
may  display  different  stages  of  evolution. 

Etiology. — The  etiology  of  the  disease  is  obscure,  some 
observers  ascribing  it  to  the  syphilitic  diathesis^  others  to 
the  most  diverse  causes,  such  as  arthritism,  alimentary 
irritations,  etc.  Hyde  and  others  suggest  a  tuberculous 
origin.  Sabouraud  asserts  (hat  the  disease  is  always  pre- 
ceded by  seborrhea  and  has  its  origin  in  the  microbacillus 
described  by  him,  followed  by  infection  with  staphylococci. 

Acne  varioliformis  should  be  distinguished  from  acne 
vulgaris  and  the  pustular  syphilide. 

Treatment. — The  existing  lesions  are  readily  cured  by 
inunctions  with  sulphur,  white  precipitate,  resorcin,  or 
boric  acid  ointments,  or  lotions  of  boric  acid  and  resorcin, 
but  relapses  are  common.  When  the  patient  is  known  to 
be  syphilitic  a  mercurial  treatment  should  be  instituted. 

One  of  us  obtained  a  virtual  cure  with  the  a>rays  in  an 
aggravated  case  which  had  for  years  resisted  a  variety 
of  approved  methods.  The  technique  was  the  same  as 
advised  under  acne  vulgaris,  the  only  adjuvant  being  the 
application  of  Kummerfeld's  lotion,  q.  v. 


HYPERTRICHOSIS  419 

AFFECTIONS  OF  THE  HAIR  FOLLICLES. 
CANITIES. 

Description. — Canities,  or  grayness  of  the  hair,  may  be 
congenital  or  acquired.  In  the  congenital  variety  the  gray- 
ness  is  usually  limited  to  tufts,  and  this  is  sometimes  observed 
to  be  a  family  peculiarity.  The  acquired  form  may  be  pre- 
mature, or  else  occur  in  the  course  of  advancing  years.  We 
have  seen  the  hair  remain  permanently  gray  in  the  affected 
regions  of  alopecia  areata.  Abrupt  changes  of  the  hair 
from  its  normal  shade  to  the  whiteness  of  age  have  been 
often  reported,  and  a  few  cases  are  on  record  in  which  the 
hair  has  changed  several  times  from  dark  to  gray  and  back 
again,  and  also  where  gray  hair  has  become  dark  in 
extremely  old  people.  The  so-called  "ringed  hair"  con- 
sists of  alternate  rings,  of  which  one  is  normal  in  color  and 
the  next  one  gray. 

The  question  of  dyes  for  the  hair  is  a  matter  for  the  hair 
dresser  and  need  not  be  considered  in  this  place.  We  may 
mention  that  certain  hair  dyes,  notably  walnut  juice,  or 
what  is  said  to  be  walnut  juice,  often  sets  up  a  severe 
dermatitis  of  the  face,  neck,  and  ears. 

WTe  have,  perhaps,  observed  10  cases  of  this  sort,  which 
had  resisted  treatment  until  the  cause  of  the  irritation  had 
been  discovered  and  removed. 

In  certain  cases  of  presenile  graying  of  the  hair,  Anderson 
recommends  attention  to  the  general  health  and  the  inter- 
nal use  of  arsenic. 

HYPERTRICHOSIS. 

Description. — Hypertrichosis,  hirsuties,  hypertrophy  of 
the  hair,  or,  as  termed  by  the  laity,  superfluous  hair,  refers 
in  a  general  way  to  that  condition  in  which  the  capillary 
growth  is  unnatural.  This  abnormality  may  be  in  respect 


420          AFFECTIONS  OF  THE  HAIR  FOLLICLES 

to  length,  thickness  of  the  hair,  to  the  situations  upon 
which  it  may  occur,  as  well  as  to  the  age  and  sex  of  the 
person  bearing  it. 

Hypertrichosis  may  be  more  or  less  general,  except  in 
places  where  normally  there  are  no  hairs,  or  it  may  be 
limited  to  certain  regions;  besides,  it  may  be  acquired  or 
congenital. 

Medical  literature  is  full  of  examples  of  rare  and  unusual 
cases  of  hypertrichosis,  but  the  dermatologist  is  practi- 
cally interested  only  in  the  facial  hirsuties  of  women. 
These  cases  are  very  distressing,  and  when  the  obnoxious 
growth  occurs  on  the  faces  of  young  women,  it  is  the  source 
of  constant  mortification  and  mental  depression,  and  in 
some  instances  leads  to  profound  melancholia.  Even  older 
women,  who  have  arrived  at  the  time  of  life  when,  as  Balzac 
says,  a  woman  takes  to  the  razor,  are  averse  to  such  a 
deformity,  and  it  is  all  the  more  distressing  to  those  of  the 
Anglo-Saxon  race,  in  which,  even  after  the  menopause,  hir- 
suties rarely  develops. 

The  character  of  the  growth  as  regards  the  amount  of 
hair,  its  texture,  and  the  locality  implicated,  differs  very 
much  in  different  cases.  In  rare  instances  there  may  be 
a  full  beard,  as  coarse  as  a  man's,1  or  the  hairs  may  be  fine 
and  comparatively  few  in  number.  In  our  experience  the 
growth  is  more  fully  developed  on  the  chin  than  elsewhere, 
next  on  the  upper  lip,  and,  lastly,  on  the  cheeks  near  the 
margin  of  the  hair. 

Often  when  the  beard  is  tolerably  full  on  the  chin  there 
will  be  but  little  hair  on  the  upper  lip,  and  then  mostly 
at  the  corners  of  the  mouth. 

The  causes  of  hypertrichosis  are  more  or  less  obscure, 
although  theories  accounting  for  its  existence  are  suffi- 
ciently numerous.  Racial  tendency,  heredity,  and  nervous 

1  The  first  operation  ever  made  by  electrolysis  for  facial  hirsutics 
was  in  the  case  of  Miss  X.,  who  had  a  patriarchal  beard.  The  case 
was  reported  by  Hardaway  in  the  St.  Louis  Medical  and  Surgical 
Journal,  November,  1877.  "  In  the  Philadelphia  Medical  News,  May 
5,  1888,  he  published  a  supplemental  account  of  this  case. 


HYPERTRICHOSIS  421 

influences  may  be  mentioned  as  probable  causative  factors. 
Unna's  theory  is  interesting.  He  believes  that  congenital 
hypertrichosis  is  due  to  a  persistence  of  the  fetal  or  primitive 
hair;  in  reality  an  arrest  of  development. 

Acquired  hirsuties  is  perhaps  often  the  result  of  local 
hyperemia,  brought  about  by  various  causes.  Growth  of 
hair  under  poultices,  and  upon  the  chests  and  arms  of 
laboring  men  exposed  to  the  heat  of  the  sun's  rays,  etc.,  are 
cases  in  point. 

Sulphur,  for  example,  is  a  most  powerful  pilary  stimu- 
lant, and  we  have  seen  a  number  of  cases  where  the  drug 
had  been  applied  for  months  or  years,  in  which  hyper- 
trichosis developed.  The  constant  frictions  were  also,  no 
doubt,  an  additional  element. 

It  is  also  asserted  that  repeated  exposure  to  the  x-rays, 
as  in  acne,  for  example,  is  followed  by  a  development  of 
hair. 

Certainly,  as  regards  facial  hirsuties,  women  of  the 
Latin  races  seem  to  be  particularly  predisposed. 

Hamilton  called  attention  some  time  ago  to  the  fact  that 
insane  women  often  suffer  from  hypertrichosis  of  the  face. 
However  this  may  be,  it  is  a  matter  of  observation  that 
superfluous  hairs  will  often  set  up  profound  derangement 
of  the  nervous  system. 

Our  experience  in  the  treatment  of  the  facial  hirsuties 
of  women,  which  has  been  unusually  large,  has  taught  us 
that  the  apparent  causes  of  this  deformity  are  by  no  means 
uniform.  We  can  emphatically  state  that  in  fully  one-third 
of  the  cases  there  existed  some  sexual  derangement,  most 
frequently  amenorrhea.  Some  few  of  the  patients  were 
more  or  less  masculine  in  voice,  figure,  and  mental  traits. 
In  no  inconsiderable  proportion  hereditary  influence  was 
strongly  marked.  The  fact  that  hairs  are  apt  to  develop 
for  the  first  time  at  the  menopause  would  seem  to  indicate 
that  derangement  or  abeyance  of  the  menstrual  functions 
possesses  a  considerable  etiological  importance.  Finally, 
in  a  certain  number  of  patients  there  were  no  ascertainable 
causes  for  the  hirsuties. 


422         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

Treatment. — The  destruction  of  the  growth  by  electrol- 
ysis is  the  only  permanent  and  satisfactory  method.  It 
was  first  proposed  by  Michel,  of  St.  Louis,  for  the  radical 
cure  of  trichiasis,  and  was  afterward  applied  to  the  facial 
hirsuties  of  women  by  one  of  us.1 

For  the  purposes  of  this  operation  it  is  necessary  to  have 
a  good  galvanic  battery,  a  number  of  fine  needles,  a  suit- 
able needle  holder,  a  sponge  electrode,  and  the  necessary 
insulated  cords.  Originally  a  delicate  sewing  needle  was 
employed,  which  was  given  up  in  favor  of  the  jeweller's 
bristle,  recommended  by  Fox;  but  of  late  years  we  use 
almost  entirely  the  iridoplatinum  needle,  originally  sug- 
gested by  one  of  us,2  which  has  the  great  advantage  of 
being  readily  bent,  and  of  not  being  easily  broken;  more- 
over, it  may  be  made  to  follow  the  course  of  the  follicle 
as  a  soft  sound  does  the  urethral  canal,  thus  rarely  pene- 
trating the  follicle  wall,  as  often  happens  with  the  stiff 
needles. 

Any  suitable  needle  holder  may  be  employed.  A  pair  of 
light  forceps  with  an  easy  spring  is  also  required.  We  make 
use  of  a  lens,  but  while  this  is  not  a  necessity,  it  greatly 
helps  along  with  the  rapidity  of  the  work. 

The  patient  being  seated  in  a  reclining  chair,  facing  a 
good  light,  the  needle  attached  to  the  negative  electrode  is 
entered  into  the  follicle,  the  hair  being  left  in  situ  as  a 
guide;  after  this  has  been  accomplished,  and  not  until 
then,  the  patient  is  told  to  place  a  couple  of  finger-tips  on 
the  previously  moistened  positive  sponge  electrode.3  The 
needle  is  not  withdrawn  until  a  slight  frothing  is  observed 

1  Hardaway,  St.  Louis  Med.  and  Surg.  Jour.,  November,  1877; 
Amer.  Dermatological  Assoc.,  1878. 

2  Hardaway. 

s  Of  late  years  it  has  been  found  much  more  satisfactory  to  place 
the  positive  electrode  in  a  goblet  or  small  bowl  of  water.  The  patient, 
instead  of  touching  the  sponge,  places  one,  two,  or  three  finger-tips  in 
the  water,  as  may  be  required.  This  simple  device  has  many  decided 
advantages.  The  usual  methods  followed  in  electrolytic  operations, 
namely,  grasping  the  sponge  with  the  whole  hand,  or  fastening  it  to 
some  portion  of  the  body,  are  barbarous,  and,  moreover,  almost 
invariably  lead  to  bad  results. 


HYPERTRICHOSIS  423 

around  its  stem,  showing  that  the  electrolytic  action  has 
been  fully  developed;  but  to  avoid  shock,  the  positive 
sponge  electrode  is  first  released  by  the  patient,  and  then 
afterward  the  needle  is  removed,  being  exactly  the  reverse 
of  the  initial  steps.  An  experienced  operator  will  find  no 
difficulty  in  introducing  the  needle  directly  into  the  follicle, 
and  he  can  be  assured  of  this  fact  by  the  following  cir- 
cumstances : 

1.  If  the  needle  miss  the  follicle,  and  pass  into  the 
surrounding  tissues,  a  sharp,  pricking  sensation  will  be 
experienced    by  the   patient,   but  if    the  instrument  be 
properly  introduced  into  the  mouth  of  the  follicle,  and 
allowed  to  sink  by  its  own  weight  (and  on  this  account  a 
moderately  heavy  holder  is  preferred)  to  the  bottom  of  the 
canal,  no  pain  will  be  felt  until  the  contact  with  the  positive 
electrode  occurs. 

2.  The  practised  operator  will  readily  detect  an  unusal 
resistance  if  the  needle  fails  to  pass  down  the  follicle. 

3.  In  the  majority  of  cases  the  proper  direction  of  the 
needle  is  manifested  by  the  appearance  of  the  sebaceous 
secretion,  and  sometimes  this  is  evident  immediately  upon 
the  passing  of  the  needle,  even  before  the  circuit  is  closed. 

As  a  rule,  a  few  seconds — twenty  to  forty — suffice  for 
the  destruction  of  the  papilla;  but  this  is  largely  a  matter 
of  experience  and  depends  upon  various  circumstances, 
such  as  the  strength  of  current  employed,  the  character 
and  situation  of  the  hairs,  etc.  If  the  electrolytic  action 
have  been  properly  developed  and  skilfully  applied,  the 
hair  will  come  away  with  the  very  gentlest  traction  of  the 
forceps — a  point  always  to  be  tested  at  once;  but  if  force 
be  required  for  its  extraction  it  is  a  sign  that  the  opera- 
tion has  been  ineffectual,  and  the  needle  must  be  rein- 
troduced  at  once,  or  the  process  may  be  repeated  at  a 
subsequent  sitting.  We  usually  employ  ten  or  twelve  cells 
of  a  freshly  charged  twenty-cell  galvanic  battery.  The 
dry-cell  chloride  of  silver  battery  is  most  convenient  for 
the  purpose,  as  it  requires  absolutely  no  attention  until 
exhausted  after  years  of  use,  but  after  a  time  the  number 


of  cells  will  have  to  be  increased.  A  current  measurer  is 
convenient,  but  not  absolutely  necessary,  as  we  know 
from  many  years'  experience.  From  2  to  4  ma.  are  suf- 
ficient. 

The  amount  of  pain  experienced  differs  in  different 
people,  and  also  according  to  the  situation  of  the  hairs;  but 
generally  a  tolerance  is  soon  established.  We  have  found  no 
benefit  from  the  local  use  of  cocaine  either  in  oleate  or 
solution. 

The  immediate  effect  of  the  electrolysis  is  the  formation 
of  an  urticarial  wheal,  with  the  production  of  a  variable 
amount  of  circumscribed  congestion  and  perifollicular 
exudation;  but  as  we  always  direct  the  patient  to  bathe  the 
parts  in  very  hot  water,  for  ten  minutes  at  a  time,  several 
times  a  day  after  each  operation,  this  local  disturbance 
readily  subsides. 

When  the  hairs  are  closely  set  it  is  not  advisable  to  pass 
from  each  to  its  next  neighbor,  but  they  may  gradually  be 
picked  out  here  and  there  at  different  sittings,  until  the 
whole  field  has  been  gone  over.  Thus,  by  the  use  of  hot 
water  to  allay  inflammation,  and  the  selection  of  different 
localities  for  operation,  the  sittings  may  be  more  frequent, 
and  the  work  considerably  expedited;  and,  moreover,  by 
using  due  caution  and  skill,  scarring  may  be  altogether 
obviated.  On  the  upper  lip,  however,  where  the  skin  is 
thin,  if  the  hairs  are  numerous,  minute  pits  may  be  pro- 
duced. 

The  same  effect  may  ensue  under  exceptional  circum- 
stances in  other  situations,  as,  for  example,  when  the 
hairs  are  very  coarse  and  abundant;  but  it  is  certainly 
exceptional.  From  twenty  to  sixty  hairs  may  be  removed  at 
each  operation,  and  the  sittings  may  usually  last  from  one- 
half  to  three-quarters  of  an  hour. 

We  believe  it  is  an  entirely  tenable  statement  that  from 
80  to  90  per  cent,  of  hairs  are  destroyed  by  the  first  opera- 
tion, assuming,  of  course,  that  proper  skill  and  suitable 
instruments  have  been  employed.  Hairs  that  return  must 
be  operated  on  again.  It  does  not  follow,  however,  that 


HYPERTRICHOSIS  425 

all  the  hairs  that  reappear  represent  operative  failures; 
on  the  contrary,  in  many  patients,  especially  young  people, 
the  tendency  to  hair  production  still  continues,  and  the 
electrolysis  must  be  repeated  from  time  to  time.  In  older 
people,  or  in  circumscribed  regions,  there  is  little  or  no 
tendency  of  this  sort,  and  the  returns  really  represent 
partial  or  complete  failures.  If  the  hair  papilla  and  the 
hair-bearing  surface  of  the  follicle  be  destroyed,  the  hair, 
of  course,  cannot  be  regenerated ;  but  it  sometimes  happens 
that  the  destruction  has  not  been  sufficiently  radical,  in 
which  case  it  is  necessary  to  do  the  work  over  again.  A 
plan  that  we  have  long  followed,  and  one  that  overcomes 
some  of  the  causes  of  failure,  is  constantly  to  move  the 
needle  up  and  down,  and  from  side  to  side,  thus  ensuring 
tolerably  extensive  destruction  in  and  about  the  hair-bear- 
ing regions. 

It  is  possibly  true  that  the  fine,  downy  hairs  interspersed 
between  the  operable  ones  are  stimulated  to  a  lustier 
growth  by  the  electrolytic  depilation,  but  of  this  we  are  not 
quite  convinced;  but,  even  if  this  does  occur,  it  makes 
very  little  difference,  as  in  time  they  would  assume  larger 
proportions,  even  if  left  alone,  and  would  have  to  suffer 
ultimate  removal. 

Bloebaum  believes  that  the  galvanocautery,  using  a 
fine  iridoplatinum  needle,  gives  better  results  than  elec- 
trolysis. From  an  experience  gained  many  years  ago,  we 
are  disposed  to  doubt  the  value  of  (his  method,  although 
it  is  possible  that  at  that  time  we  may  have  employed  a 
faulty  technique. 

Kromayer  has  recently  advised  the  use  of  a  fine  cutane- 
ous punch  driven  by  a  motor  or  dental  engine.  He  claims 
that  100  or  more  hairs  can  be  removed  at  a  sitting,  and 
that  the  operation  is  not  unduly  painful  and  leaves  no 
visible  scars. 

Other  methods  of  removing  hair,  such  as  by  shaving, 
epilation,  depilatories,  etc.,  are  of  no  permanent  value,  and 
by  unduly  stimulating  the  growth  are  productive  of  more 
harm  than  good.  If,  however,  for  any  reason,  it  is  desired 


426         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

to  employ  a  depilatory,  the  best  results  are  obtained  from 
Boettger's  paste  of  calcium  sulphydrate,  which  is  highly 
recommended  by  Dr.  A.  W.  Brayton. 

In  some  instances,  as  suggested  by  Bulkley,  peroxide 
of  hydrogen  may  be  employed  to  bleach  a  slight  growth 
of  hair,  thus  rendering  it  quite  inconspicuous,  but  we 
have  not  noticed  that  this  practice  in  any  way  retards  the 
growth. 

The  X-rays. — In  order  to  estimate  properly  the  value  of 
the  x-rays  for  this  purpose,  we  must  be  informed  as  to  the 
manner  in  which  a  hairy  region  reacts  to  the  rays. 

The  first  effect  of  the  rays,  or  the  effect  of  a  mild  dose, 
is  to  stimulate  the  cells  of  the  papilla.  This  is  the  reaction 
sought  for  in  the  treatment  of  alopecia  areata.  A  larger 
dose  will  cause  shedding  of  the  hair  without  precedent 
erythema.  With  a  dose  again  a  little  increased,  there 
occurs  alopecia  preceded  by  erythema.  So  far  the  effect 
on  the  hair  papilla  is  transitory.  Within  a  short  time, 
usually  two  months,  the  lost  hair  reappears.  This  tem- 
porary alopecia,  with  or  without  erythema,  is  the  desidera- 
tum in  the  treatment  of  tinea,  favus,  and  sycosis. 

With  a  still  larger  dose  there  may  be  severe  dermatitis, 
with  complete  destruction  of  the  hair  papilla  and  conse- 
quent permanent  alopecia.  Unfortunately  the  destruction 
will  not  be  limited  to  the  papilla,  but  will  involve  other 
structures,  thus  resulting  in  scarring. 

If  the  dose  sufficient  to  produce  a  temporary  alopecia  be 
repeated  a  number  of  times,  waiting  each  time  for  the 
disappearance  of  all  inflammatory  reaction,  there  will 
finally  be  induced  a  permanent  atrophy  of  the  papilla. 
While  such  a  process  need  not  involve  scarring,  the  atrophy 
cannot  be  limited  to  the  papilla,  so  that  a  certain  amount  of 
general  atrophy  will  always  be  present.  Besides  atrophy, 
certain  other  late  reactions,  such  as  pigmentation  and 
telangiectasis,  may  supervene.  Even  after  a  single  "nor- 
mal" exposure  (see  p.  566)  of  4  to  6  H,  according  to 
Kienbock,  late  cutaneous  atrophy  may  develop  and  con- 
tinue for  many  months. 


HYPERTRICHOSIS  427 

The  oxray  treatment  of  hypertrichosis  must,  therefore, 
steer  its  way  between  such  doses  as  will  stimulate  hair 
growth,  or  cause  a  merely  temporary  alopecia,  on  the  one 
hand,  and  such  as  will  cause  severe  inflammation  and 
possibly  deep  destruction  on  the  other.  Between  these 
extremes  lie  the  dangers  of  late  general  atrophy  and 
telangiectasis.  The  fact  pointed  out  by  Pusey,  that  the 
reaction  required  to  cause  removal  of  the  hair  varies  con- 
siderably in  different  individuals,  makes  it  impossible  to 
obtain  one's  end  without  running  a  serious  risk. 

The  same  observer,  equally  distinguished  for  his  success 
and  his  caution,  says:  "The  method  is  so  tedious  and  so 
beset  with  difficulties  that  I  hesitate  to  advise  it  except  in 
cases  of  hypertrichosis  of  exaggerated  type."  Altogether, 
at  least  with  our  present  knowledge  of  technique,  the 
procedure  does  not  seem  to  us  justified.  Hypertrichosis 
is  not  a  disease,  entails  no  physical  pain,  and  can  be  dealt 
with  by  other  and  less  risky  methods.  The  cases  to  which 
electrolysis  is  not  applicable,  such  as  those  wh!ch  present 
a  copious  growth  of  long,  fine,  downy  hairs,  are  precisely 
those  in  which  the  rays  fail  most  signally. 

The  process  is  a  very  slow  one.  Thus,  Freund,  in  order 
to  secure  a  permanent  result,  after  the  first  fall  of  hair,  gives 
monthly  exposures  for  a  year  and  one-half.  Kienbock 
says  that  a  permanent  alopecia  cannot  be  secured  in  less 
than  a  year  or  so  of  treatment  by  repeated  irradiations 
of  slight  intensity,  and  that  other  methods  with  the  rays 
are  dangerous. 

In  one  of  Pusey's  cases  there  was  "a  considerable  return 
of  hair"  after  one  hundred  and  six  sittings.  A  case  which 
he  regards  as  "entirely  satisfactory"  received  over  seventy- 
five  sittings  and  at  one  time  developed  an  acute  dermatitis 
which  "caused  much  anxiety."  In  another  the  improve- 
ment was  "not  satisfactory,"  after-treatment  extending 
over  three  years. 

Belot  gives  supplementary  rayings  of  five  or  ten  minutes 
every  two  months,  and  gives  it  as  his  opininon  that  "by 
this  means  we  may  hope  to  obtain  a  permanent  alopecia 


428          AFFECTIONS  OF  THE  HAIR  FOLLICLES 

after  treatment  for  two  years."  Unfortunately,  however, 
the  fear  of  having  worked  irretrievable  injury  will  not  be 
allayed  with  the  termination  of  treatment,  but  will  haunt 
the  operator  long  after.  The  gist  of  the  whole  matter,  as 
it  seems  to  us,  is  that  the  condition  is  not  sufficiently  serious 
to  justify  the  risks,  some  of  which  are  unavoidable. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Barii  sulphidi 5ij 

Zinci  oxidi, 

Pulv.  amyli aa     5iij — M. 

S. — Depilatory.  To  be  made  into  a  paste  with  water  just  before 
applying.  Remove  in  a  few  minutes,  or  as  soon  as  a  sensation  of 
warmth  occurs,  and  then  apply  a  soothing  ointment.  Duhring. 

1$ — Orpiment 3ss 

Calcis  vivae Sss 

Farinae  tritici 9ij 

Aquae  fervid q.  s. — M. 

S. — Apply  as  a  paste.  Kaposi. 


ATROPHIA  PILORUM  PROPRIA. 

Description. — Atrophy  of  the  hair  occurs  as  the  result 
of  various  local  diseases  of  the  scalp,  such  as  eczema, 
seborrhea,  and  the  parasitic  affections,  and  also  as  an 
attendant  upon  general  constitutional  disorders  such  as 
phthisis,  syphilis,  etc.  Such  atrophy  may  be  called  symp- 
tomatic fragilitas  crinium.  In  idiopathic  fragilitas  crinium 
there  is  no  apparent  general  cause  for  the  atrophy  of  the 
hair.  In  these  cases  the  hair  is  dry  and  brittle  and  splits 
at  the  free  ends,  or  the  shaft  of  the  hair  is  thinner  at  one 
point  than  at  another,  showing  somewhat  regular  irregu- 
larities. In  a  case  reported  by  Duhring  the  hair  began  to 
split  within  the  bulb,  and  there  was  much  accompanying 
irritation  of  the  skin.  Hyde  records  a  somewhat  similar 
case. 

Jackson  recommends  that  when  the  free  end  of  the 
hair  is  involved  it  should  be  cut  above  the  cleft,  and 
says  that  if  the  beard  is  affected  shaving  will  remove  the 


TRICHORREX1S  NODOSA  429 

deformity  and  very  probably  bring  about  a  cure.  Singe- 
ing has  much  the  same  effect  as  clipping.  The  latter 
must  be  done  with  very  sharp  scissors,  only  a  few  hairs 
being  cut  at  each  snip. 


TRICHORREXIS  NODOSA. 

Description. — Trichorrexis  nodosa  usually  invades  the 
hairs  of  the  beard  in  the  male,  but  it  is  occasionally  met 
with  in  the  hair  of  the  head,  and  also  among  women. 
To  the  touch  the  hairs  feel  irregular  and  knotty,  and  upon 
casual  inspection  the  beard  looks  ragged,  and  as  if  the 
ends  had  been  singed.  Upon  closer  inspection  there  will 
be  observed  along  the  hair  shaft,  shining,  bulbous  swellings, 
looking  not  unlike  the  ova  of  pediculi.  The  hairs  are 
firmly  seated  in  the  papillae,  but  fracture  readily,  the 
break  occurring  through  the  nodes.  These  little  nodes  are 
due  to  the  splitting  apart  of  the  hair  filaments,  presenting 
an  appearance  as  if  the  ends  of  two  brushes  had  been 
pressed  together  and  interlocked. 

Raymond  says  that  the  disease  is  common  on  the  hairs 
of  the  labia  majora,  especially  in  fat  women,  and  also  on 
the  scrotal  hairs  in  men.  He  believes  it  to  be  communicable, 
which  fact  would  explain  the  apparently  hereditary  nature 
of  a  number  of  reported  cases. 

Hodara  and  others  have  described  various  microorgan- 
isms in  connection  with  this  condition,  but  this  explanation 
is  not  universally  admitted,  and  it  is  believed  by  many  that 
mechanical  causes  or  nutritional  changes  in  the  hair  may 
be  largely  responsible. 

The  treatment  of  these  cases  is  not  very  encouraging. 
Schwimmer  recommends  the  following  ointment,  which 
may  be  rubbed  in  morning  and  evening: 

]} — Zinci  oxidi gr.  vij 

Sulphuris  loti gr.  xv 

Ung.  aquae  rosse oss — M. 


430         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

Sabouraud  speaks  highly  of  a  lotion  made  in  this  way: 

1$ — Hydrarg.  bichloridi gr.  iv 

Acidi  tartarici gr.  viij 

Resorcini gr.  xv-xxx 

Alcoholis, 

^Etheris aa  5jss — M. 

Besnier  advocates  plucking  the  hairs  and  the  application 
of  pure  or  dilute  tincture  of  cantharides.  Shaving  may  be 
tried. 

MONILETHRIX. 

Description. — This  disease,  which  was  first  described  by 
W.  G.  Smith,  affects  usually  only  the  hair  of  the  scalp,  and 
may  be  confined  to  localized  areas  at  the  temples,  the 
crown  or  the  back  of  the  head.  The  hair  is  fine,  sparse, 
and  brittle,  and  the  affected  parts  have  the  appearance  of 
being  bald ;  there  is  also  present  a  marked  degree  of  kera- 
tosis  pilaris. 

The  hairs  present,  along  their  shafts,  a  series  of  smooth, 
solid  nodes  that  extend  from  deep  in  the  follicle  to  their 
ends.  The  internodal  parts  of  the  hair  are  lighter  in  color 
than  the  apparently  nodular  parts.  The  fracture  always 
occurs  in  the  part  of  the  shaft  between  the  rings,  wherein 
it  differs  from  trichorrexis  nodosa.  This  disorder  is  con- 
sidered practically  congenital,  inasmuch  as  it  occurs  very 
early  in  life,  but  it  would  seem  that  there  are  exceptions 
to  this  rule.  It  would  also  appear  to  be  an  hereditary 
affection.  There  is  no  distinctly  curative  treatment. 


LEPOTHRIX. 

Description. — This  disorder,  first  described  by  Paxton 
in  1809,  affects  principally  the  axillary  hairs  and  those 
situated  on  the  genital  regions.  Upon  microscopic  exam- 
ination the  shafts  of  the  hairs  are  found  to  be  the  seat  of 
firm  concretions,  sometimes  ensheathing  them  and  some- 
times arranged  in  the  form  of  irregular  nodules.  The 


FOLLICULITIS  CAPILLITII  DESQUAMATIVA      431 

hairs  readily  fracture,  and  to  the  unaided  eye  appear  rough 
and  without  lustre.  The  masses  are  of  an  orange  or  red 
color,  the  latter  due  to  the  coexistence  of  red  sweat.  The 
disorder  is  due  to  zooglea  masses  of  elliptical  cocci  sur- 
rounding the  hair.  Montgomery  recommends  the  follow- 
ing lotion: 

1$ — Hydrarg.  bichloridi       .      .      .      .      .      .      .     gr.  vii j 

Alcoholis  dilut §iv — M. 

S. — To  be  sopped  on  either  with  the  hand  or  with  absorbent  cot- 
ton, once  a  day  after  washing. 


PIEDRA. 

Description. — Dr.  N.  Osorio,  of  Bogota,  first  described 
this  affection  in  1876.  It  is  almost  exclusively  found  in 
Colombia  and  among  women.  The  concretions  are  black, 
stone-like  (hence  the  name)  particles  scattered  irregularly 
along  the  shaft  of  the  hair,  beginning  one-fourth  to  one-half 
inch  from  the  root  and  extending  to  the  point.  The  disease 
is  caused  by  a  fungus. 

TINEA  NODOSA. 

Description. — Morris  and  Cheadle  first  described  this 
fungus  disorder  of  the  hairs  of  the  whiskers  or  moustache. 
The  nodules  consist  of  fungus  spores  similar  to  those  of 
trichophyton.  Parasiticides  freely  applied,  and  shaving 
or  clipping  the  hairs  will  effect  a  cure. 

FOLLICULITIS  CAPILLITII  DESQUAMATIVA. 

Description. — One  of  us1  elsewhere  described  a  case  in 
which  small,  grayish-white  bodies  closely  resembling  nits, 
were  strung  beadwise  along  the  hair.  They  consisted  of  a 
mass  of  cells  of  the  internal  root-sheath  which  had  be- 

1  Grindon,  Journal  Cutaneous  Diseases,  1897,  p.  256. 


432         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

come  loosened  en  masse  and  were  carried  up  on  the  hair 
in  its  growth.     There  were  slight  perifollicular  inflamma- 
tion and  alopecia.    Beigel  described  a  similar  case. 
Treatment  was  by  epilation. 


ALOPECIA. 

Description. — This  is  a  general  term  used  to  denote 
various  degrees  of  loss  of  hair  arising  from  various  causes. 
Alopecia  has  been  divided  into  the  following  varieties: 

Congenital  Alopecia. — Often  the  alopecia  is  only  tem- 
porary, hair  of  normal  calibre  making  its  appearance  in 
after-life.  If  the  congenital  baldness  is  limited  to  a  small 
portion  of  the  skin  the  defect  is  apt  to  be  permanent. 

Senile  Alopecia. — The  loss  of  hair  in  the  aged  generally 
begins  on  the  crown  of  the  head,  and  spreads  gradually 
forward,  then  sideways  and  backward.  Women  retain 
their  hair  longer  than  men.  There  are  accompanying 
atrophy  of  the  skin  and  other  evidences  of  advancing  years. 

Idiop  at  hie  Premature  Alopecia. — In  many  persons,  long 
before  middle  age,  the  hair  begins  slowly  to  fall  out,  and 
follows  the  course  common  to  senile  alopecia,  except  that 
there  has  been  no  antecedent  grayness.  The  process  is 
usually  very  gradual;  the  first  strong  hairs  are  shed,  and 
are  then  replaced  by  those  of  weaker  growth,  and  so  on 
until  the  parts  are  left  bare  and  shining.  The  hairs  of  the 
beard  generally  retain  their  pristine  vigor.  This  condition 
is  often  hereditary.  It  is  more  than  likely  that  further 
observations  will  show  that  most  of  these  cases  are  in 
reality  due  to  definite  morbid  states. 

Symptomatic  Premature  Alopecia. — As  its  name  indi- 
cates, this  form  of  baldness  is  an  abnormal  loss  of  hair  due 
to  a  variety  of  causes.  It  may  be  partial  or  general.  The 
eitological  factors  in  its  production  are  numerous,  of  which 
the  more  frequent  are  general  disturbances  of  nutrition, 
fever,  mental  emotion,  dyspepsia,  and  prolonged  overwork, 
and  among  the  local  causes  are  to  be  noted  seborrhea, 


ALOPECIA  433 

eczema,  lupus  erythematosus,  variola,  erysipelas,  syphilis, 
and  leprosy.  Syphilitic  alopecia  is  usually  an  early  mani- 
festation of  the  diathesis,  but  may  supervene  later  with 
the  tubercular  and  gummatous  lesions. 

In  our  experience,  women  suffer  more  frequently  than 
men  from  sudden  thinning  of  the  hair,  and  we  have 
observed  that  this  condition  may  occur,  without  apparent 
local  cause,  at  irregular  intervals.  We  are  almost  convinced 
that,  in  some  instances  at  least,  menstrual  disturbances 
bear  a  relation  to  the  alopecia. 

Syphilis  may  also  induce  loss  of  hair  in  other  regions 
than  the  scalp;  for  example,  in  the  eyebrows  and  over  the 
pubes,  especially  in  women. 

In  the  form  of  the  disease  known  as  alopecia  follicularis, 
when  the  scalp  has  been  invaded  by  the  parasites  of  ring- 
worm or  favus,  the  baldness  may  be  permanent,  especially 
when  due  to  the  presence  of  the  Achorion  Schoenleinii. 

Alopecia  Pityrodes. — This  disease,  also  known  as  alo- 
pecia furfuracea  and  pityriasis  capitis,  is  exceedingly  fre- 
quent, and  one  of  the  most  common  causes  of  early  baldness. 
It  is  rare  before  puberty,  and  is  of tener  observed  in  men  than 
in  women.  One  of  the  earliest  symptoms  to  attract  atten- 
tion is  the  dandruff  which  falls  freely  over  the  coat  collar 
and  even  may  be  seen  in  the  hair  as  a  fine  dust.  After  the 
pityriasis  has  existed  from  five  to  seven  years,  as  a  general 
thing,  the  patient  is  alarmed  by  finding  that  the  daily  loss 
of  hair  is  relatively  greater  than  formerly.  In  the  combings 
are  found  an  increased  number  of  "  pointed  hairs,"  or  hairs 
that  have  failed  to  reach  a  full  growth,  but  approach  in 
type  to  lanugo.  This  process  continuing,  all  the  hairs  in 
the  affected  areas  become  converted  into  lanugo,  until,  at 
last,  even  the  downy  growth  disappearing,  the  scalp  is  left 
bald  and  ivory-like  in  appearance.  Subjective  sensations 
in  the  form  of  burning,  tingling,  or  itching  are  sometimes 
complained  of  by  patients. 

At  times  the  more  distinctly  seborrheal  character  of  the 
affection   may  be   noted,   the   scales   being   thicker   and 
greasier. 
28 


434         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

Although  clinically  all  cases  of  pityriasis  of  the  scalp 
do  not  lead  to  baldness  or  even  shedding  of  the  hair,  which 
fact  Unna  explains  on  histological  grounds,  it  has  long  been 
known  (Pincus)  that  this  form  of  loss  of  hair  is  invariably 
associated  with  an  abundant  dandruff.  This  pityriasis  is 
now  regarded  by  Unna  as  a  symptom  of  chronic  desquama- 
tive  catarrh  of  parasitic  nature — the  so-called  seborrheic 
eczema  of  the  scalp.  According  to  Sabouraud  common 
alopecia  is  a  consequence  of  chronic,  oily  seborrhea,  while 
alopecia  areata  is  seen  with  the  acute  form.  The  so-called 
seborrheal  cocoon,  he  states,  found  in  the  upper  part  of 
the  hair  follicle,  between  its  opening  and  that  of  its 
sebaceous  orifice,  contains  in  its  undegenerated  stage  an 
immense  quantity  of  an  almost  pure  vegetation  of  a 
microbacillus.  The  bacillus  itself,  being  circumscribed  in 
the  upper  third  of  the  hair  follicle,  does  not  reach  the 
papilla,  but  the  lethal  influence  is  produced  by  toxins 
generated  in  the  neighborhood  of  the  cocoon.  This  is 
not  the  place  to  discuss  the  different  views  of  Unna  and 
Sabouraud,  but  the  practical  fact  remains  that  the  thera- 
peutics of  these  various  affections  must  be  based  on  the 
theory  of  parasitism.  Granting  the  parasitic  nature  of  the 
disorder,  it  is  likely  that  a  suitable  soil,  such  as  is  fur- 
nished by  debility,  anemia,  etc.,  may  be  a  prerequisite  for 
the  development  of  the  microorganisms.  The  disorder 
should  be  presumptively  contagious,  but  the  evidence  is 
negative  in  this  direction.  However,  the  greater  frequency 
of  baldness  in  men  than  in  women  may  be  due  to  the  fact 
that  the  former  are  more  commonly  exposed  to  infection 
in  barber  shops. 

In  addition  to  the  alopecia  pityrodes  capillitii  just 
described,  Michelson  calls  attention  to  a  universal  form 
of  the  disease. 

Prognosis. — The  prognosis  of  the  various  forms  of 
baldness  will  naturally  depend  upon  the  character  of  the 
predisposing  or  exciting  causes  back  of  them.  The  bald- 
ness resulting  from  local  diseases  of  the  scalp  of  a  superficial 
character,  e.  g.,  eczema  and  erysipelas,  always  ends  in 


ALOPECIA  435 

recovery,  while  deep-seated  processes,  where  ulceration  and 
consequent  scarring  occur,  leave  permanent  alopecia  in 
their  wake.  The  acute  loss  of  hair  following  fevers,  etc., 
is  usually  only  temporary.  The  outlook  in  the  idiopathic 
form  of  premature  alopecia  is  always  gloomy.  Much  can 
be  done  for  alopecia  pityrodes  if  the  case  is  seen  in  the 
first  stage  of  the  disorder,  before  the  scalp  has  become  bald 
and  adherent;  but  even  then  the  utmost  fidelity  to  instruc- 
tions must  be  insisted  upon,  and  the  patient  must  be  plainly 
told  that  time  is  an  important  element  in  the  treatment. 

Treatment. — In  congenital  baldness  no  particular  plan 
of  treatment  is  demanded,  as  the  condition  soon  corrects 
itself;  and  in  senile  alopecia  all  medication  is  useless. 
Neither  can  we  hope  to  effect  much  in  idiopathic  premature 
baldness.  Attention  to  the  general  health,  together  with  a 
strict  surveillance  of  the  habits  and  diet  of  the  patient,  and 
the  use  of  local  stimulating  applications,  are  the  means 
to  be  tried.  The  following  preparations  are  worthy  of 
attention : 

1$ — Quinina-  sulphatis gr.  x 

Spt.  myrcite Siij 

Glycerini 5j 

Sodii  chloridi 3ij 

Aquae q.  s.  ad  §viij — M. 

S. — Local  use. 

Skinner  recommends  the  following  combination  as  a 
highly  effective  stimulant  and  antiseptic  for  the  scalp : 

1$ — Acidi  salicylici gr.  xv 

Resorcini 3ss 

Tr.  cantharidis 3ss 

Tr.  capsici oj 

Saponin 5j 

Lanolini 5j 

Aquam  rosam q.  s.  ad  3x — M. 

Another  formula  given  by  the  same  writer  is  made  thus: 

T$ — Tr.  cantharidis oxiv 

Tr.  cinchonse 5ij 

Tr.  benzoin 5vj 

Spt.  lavandulac 3jss 

Olei  ricini 3ij 

Alcoholis q.  s.  ad  3x — M. 


436         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

1^ — Sulphuris  praecip oj 

Vaselini 3j 

Olei  limonis  .  . ' q.  s.  — M. 

S. — Rub  in  thoroughly  every  night. 

Jackson,  an  authority  on  this  subject,  thinks  poorly  of 
"hair  tonics"  and  insists  that  the  best  results  are  got  from 
attention  to  the  general  health  of  the  patient,  massage  of 
the  scalp,  and  daily  systematic  and  deep  brushing. 

Massage  does  not  mean  rubbing  the  scalp.  It  should 
rather  be  directed  to  moving  the  skin  about  on  the  under- 
lying fascia,  thereby  stimulating  increase  of  blood  supply. 
The  scalp  should  be  grasped  with  the  outspread  fingers  of 
both  hands  and  moved  forward  and  backward,  from  side 
to  side,  and  with  a  circular  movement,  using  a  moderate 
amount  of  force.  This  done  for  five  minutes  twice  a  day 
is,  perhaps,  the  most  valuable  of  our  therapeutic  resources 
in  simple  uncomplicated  baldness. 

Stel wagon  employs  faradism  with  a  metallic  brush  or 
comb,  or  static  electricity,  several  times  a  week. 

There  is  one  agent,  that  we  have  used  with  really  good 
results  in  the  so-called  symptomatic  alopecia,  especially 
in  women,  and  that  is  the  high-frequency  current.  We 
employ  the  ordinary  hammer-shaped  glass  electrode, 
holding  it  about  one-fourth  inch  from  the  scalp,  and  keep 
up  the  application  for  something  like  ten  minutes.  The 
sittings  may  be  repeated  two  or  three  times  a  week. 

The  various  forms  of  symptomatic  alopecia  must  be 
treated  according  to  the  indications  presented  by  the 
primary  affection.  The  acute  loss  of  hair,  defluvium  capil- 
lorum,  following  fevers,  tends  to  spontaneous  recovery. 
Shaving  the  scalp,  as  often  advised  by  wig-makers,  is 
unnecessary,  and,  we  think,  harmful.  If  the  patient  insists 
upon  something  being  done  any  of  the  local  stimulating 
preparations  may  be  prescribed.  In  syphilitic  alopecia, 
besides  the  constitutional  treatment,  recourse  may  be  had 
to  the  daily  inunction  of  5  per  cent,  oleate  of  mercury  or  the 
application  of  a  bichloride  of  mercury  lotion. 

In  alopecia  pityrodes,  as  in  most  diseases  with  a  bad  prog- 


ALOPECIA  437 

nosis,  the  number  of  remedies  proposed  is  very  large.    The 
general  indication  is  for  stimulating  applications. 

In  order  to  cleanse  the  scalp  of  dandruff  the  parts  are  to 
be  shampooed  thoroughly  with  the  tincture  of  green  soap:1 

I$— Saponis  olivjp  pnep 5iv 

Spt.  odorati Siv — M. 

S. — Shampoo. 

A  tablespoonful  of  this  mixture  is  poured  upon  the 
head  and  immediately  afterward  a  teacupful  of  lukewarm 
water;  this  results  in  a  copious  lather  with  which  the  scalp 
is  energetically  shampooed;  then  the  lather  is  washed  out 
with  at  least  a  pitcherful  of  warm  water. 

Every  night  a  very  small  quantity  of  a  salve  is  rubbed 
directly  into  the  scalp,  and  generally  in  five  or  six  days  the 
shampooing  is  repeated.  Patients  should  be  warned  not 
to  put  their  fingers  in  the  salve  box,  but  to  take  out  the 
required  quantity  on  the  end  of  a  toothpick  or  some  similar 
implement. 

Our  preference  is  usually  for  sulphur  and  salicylic  acid 
as  local  stimulants,  prepared  in  the  following  way: 

1$ — Acidi  salicylici 9j 

Sulphuris  prtecip 3j-3ij 

Aquae n^xlv 

Endermol      • q.  s.  ad  3j 

Olei  limonis q.  s. — M 

This  prescription  is  also  excellent,  but  more  greasy  than 
the  preceding: 

1^ — Acidi  salicylici 

Sulphuris  prsecip 

Vaselini 3j 

Olei  limonis q.  s. — M. 

Usually  in  five  days  the  shampooing  should  be  repeated. 
In  our  judgment  there  is  no  pilary  stimulant  so  useful  as 

1  We  always  employ  Bagoe's  prepared  olive  soap,  as  first  suggested 
by  Fox.  Tne  sapo  viridis  of  the  shops  is  a  much  inferior  article, 
and  Havoc's  can  he  substituted  for  it  with  advantage  where  <irern 
soap  is  indicated.  A  similar  soap  known  as  Moeller's  is  extremely 
good. 


438         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

sulphur,  and  under  the  plan  of  treatment  just  outlined, 
and  adhered  to  for  months,  we  have  seen  alopecia  pity- 
rodes  very  much  benefited.  A  formula  recommended  by 
Lassar,  containing  pilocarpine,  is  very  valuable,  but  it  is 
difficult  to  prepare  properly  and  has  the  disadvantage  of 
being  very  costly: 

1$ — Pilocarpinse  hydrochlor gr.  xviij 

Quininae  hydrochlor Qij 

Sulphuris  praecipitati 3jss 

Balsami  peru'viani gr.  clxxx 

Medul.  bovin Sij — M. 

If,  for  any  reason,  salves  are  not  indicated,  although  that 
form  of  preparation  gives  the  best  results,  recourse  may  be 
had  to  lotions.  Montgomery  recommends  a  bichloride 
lotion : 

1$ — Hydrarg.  bichloridi gr.  iv 

Alcoholis, 

Aquae  destillatae aa     5ij — M. 

S. — Apply  by  parting  the  hair,  and  rubbing  well  into  the  scalp 
every  day  or  second  day. 

We  are  not  at  all  partial  to  the  use  of  the  bichloride,  as 
we  have  often  seen  considerable  dermatitis  of  the  scalp 
and  neighboring  skin  caused  by  its  use  in  solutions  of 
moderate  strength. 

If  the  soap  and  alcohol  extract  too  much  oil  from  the 
hair,  a  little  olive  oil  may  be  used  to  counteract  this  effect. 
A  carbolic  acid  lotion  is  often  beneficial : 

1$ — Acidi  carbolici 9j 

Olei  limonis 3jss 

Glycerin! 5ij 

Spt.  odorati q.  s.  ad     5ij — M. 

S. — Apply  to  scalp  with  a  medicine  dropper,  and  then  brush  in 
thoroughly. 

Morris  has  seen  good  results  from  chloral : 

1$ — Chloral,  hydratis 3iij 

Alcoholis  " Sss 

Glycerini •  .  .  .  oij 

Aquam  rosam q.  s.  ad  5vj — M. 

S. — Rub  in  thoroughly  night  and  morning. 


ALOPECIA  439 

For  the  first  stage  of  the  disease  Pincus  recommends  a 
tolerably  concentrated  mixture  of  sodium  bicarbonate, 
but  it  is  objectionable  owing  to  the  discoloration  of  the 
hair  that  results. 

Ihle  has  employed  resorcin  with  good  effect : 

1^ — Resorcmi  pur gr.  xlviij 

Olei  ricini 5vij 

Spt.  vini 5iij 

Balsami  peruviani         tt^v — M. 

S. — Apply  at  night  by  means  of  a  medicine  dropper,  and  then  rub 
in  vigorously  with  a  flannel  rag. 

Elliot  recommends  a  lotion  of  3  to  10  per  cent,  resorcin 
in  equal  parts  of  alcohol  and  water,  or  3  to  5  per  cent, 
resorcin  ointment  may  be  used  once  or  twice  a  week  or  in 
alternation  with  the  lotion.  Brayton  employs  a  lotion  of 
salicylic  acid  and  resorcin  in  equal  parts  of  alcohol  and 
water.  A  combination  that  is  often  serviceable  is  the 
following: 

ty — Resorcini gr.  xlviij 

Tannin, 

Chloralis aa  ojss 

Tr.  benzoini 5ss 

Ol.  ricini 5ij-5iv 

Alcoholis q.  s.  ad  5viij — M. 

Bronson's  pomade  is  also  serviceable: 

1$ — Hydrarg.  ammoniati 9j 

Hydrarg.  chloridi  mitis 3ij 

Vaselini 3j — M. 

S. — Apply  once  or  twice  daily. 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Olei  rosmarini  , 5iv 

Tr.  cantliaridis 5iv 

Olei  amygdal.  dulc 3ij 

Spt.  camphoric S'ij 

Glycerini 3j 

Olei  rosae ...  gtt.  viij 

Pilocarpin.  hydr gr.  v — M. 

S. — To  be  well  rubbed  in  night  and  morning.  Whitla. 


440         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

1^ — Resorcini 3j 

Quininae  (alkaloid) .  gr.  xv 

Ol.  ricini       .  rr^x-xxx 

Alcoholis       .      .      .      .      .      .      .      q.  s.  ad  3iv — M. 

S. — External  use.  Stelwagon. 

1$ — Liq.  carbonis  deterg 5j 

Hydrarg.  ammoniati •  9j 

Vaselini 3j— M. 

S. — External  use.    For  seborrheal  alopecia. 

1$ — Tr.  cantharidis 5vj 

Glycerini 3ij 

Tr.  nucis  vomicae 3ss 

Acet.  destillatae 5ss 

Aquae  rosac  .  .  .  .  .  .  .  q.  s.  ad  3vj — M. 

S. — External  use.  Tilbury  Fox. 

Jfc — Acidi  acetici 3ij 

Pulv.  boracis 3ss 

Glycerini 3jss 

Spt.  vini 3ij 

Aquae  rosae   .      .  ' 3iv — M. 

S. — External  use.  Cottle. 

1$ — Pilocarpinar  hydrochlor 

Aqua*  destillatao 

Fiat  solutio  et  adde : 

Lanolinum 3x 

Oleum  petrolii 3vj 

Oleum  bergamottae 3ss 

Oleum  verbena? 5ss — M. 

Whitla. 


ALOPECIA  AREATA. 

Description. — In  this  peculiar  and  striking  form  of 
alopecia  the  hair  falls  out  more  or  less  suddenly,  exposing 
to  view  one  or  several,  circumscribed,  circular  patches  that 
are  entirely  bald.  The  scalp  is  the  part  usually  involved, 
but  other  hairy  regions,  such  as  the  beard,  eyebrows,  etc., 
may  be  implicated,  and,  as  will  be  seen  presently,  the  whole 
body  may  be  divested  of  its  hairy  growth.  Sometimes  the 
disease  is  ushered  in  by  certain  premonitory  symptoms, 
either  in  the  shape  of  a  severe  persistent  or  periodic  head- 


ALOPECIA  AREATA  441 

ache,  or  there  are  present  considerable  burning  and  local- 
ized pruritus.  However,  these  antecedent  symptoms  and 
sensations  are  not  apparent  in  the  majority  of  attacks,  and 
most  patients  are  otherwise  in  the  enjoyment  of  good 
health. 

In  most  instances  the  denuded  areas  are  white,  ivory- 
like,  and  apparently  depressed;  in  an  early  stage  of  the 
disorder  they  may  be  slightly  hyperemic.  The  sensibility 
of  the  affected  patches  is  considerably  lessened.  There 
may  be  one  or  several  patches  present,  varying  in  extent 
from  the  diameter  of  a  silver  quarter-dollar  to  the  size 
of  the  palm.  At  the  periphery  of  an  extending  patch  the 
hairs  are  short  and  easily  extracted,  and  exhibit  club-like 
extremities.  When  recovery  is  about  to  set  in,  fine  woolly 
hairs  will  first  make  their  appearance,  which  in  turn  will 
likely  fall  out,  to  be  succeeded  by  a  still  stronger  growth  of 
light  hair,  that  gradually  becomes  normal  in  color  and 
stoutness.  The  hair  may  come  in  quite  gray  and  so  remain. 
Relapses  are  more  frequent  than  is  commonly  believed. 
One  of  our  patients  had  an  attack  every  spring  for  three 
or  four  years,  evidently  the  result  of  severe  training  for  boat- 
racing. 

In  the  form  of  the  disease  properly  called  malignant 
alopecia  the  whole  hairy  system  may  be  involved,  as, 
for  example,  the  hairy  scalp,  beard,  eyebrows,  eyelashes, 
pubic  hairs,  and  even  the  hairs  of  the  extremities.  Occa- 
sionally vitiligo,  atrophic  condition  of  the  nails,  morphea, 
and  scleroderma  have  been  found  associated  with  alopecia 
areata. 

Etiology. — While  it  is  a  common  experience  that  cases 
of  alopecia  areata  are  generally  limited  to  a  single  member 
of  a  family,  even  where  the  opportunities  for  contagion  are 
of  the  best,  it  is  nevertheless  true  that  epidemics  of  a  disease 
resembling  it  in  clinical  features  have  been  observed, 
especially  in  France. 

The  influence  of  nervous  shock,  mental  anxiety,  over- 
work, and  of  direct  injury,  in  the  production  of  alopecia 
areata  cannot  be  doubted;  and  there  is  no  question  that 


442         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

the  majority  of  cases  encountered  in  this  country  owe 
their  existence  to  some  of  these  causes.  There  is  also  a 
disorder  characterized  by  baldness  in  areas  which  is 
probably  parasitic,  but  it  would  hardly  be  profitable  to 
recall  all  of  the  researches  in  this  direction,  since  they  have 
been  largely  contradictory  and  have  lacked  confirmation. 
Sabouraud  has  declared  that  alopecia  areata  and  common 
alopecia  are  due  to  the  same  cause — a  manifestation  of 
seborrhea  which,  as  is  well  known,  he  believes  is  due  to  a 
definite  microorganism. 

Diagnosis. — It  would  be  possible  to  confound  alopecia 
areata  with  tinea  tonsurans;  but  the  course  and  clinical 
history  of  the  two  affections  are  quite  different,  and  in 
case  of  doubt  a  microscopic  examination  of  the  hairs  would 
settle  the  question.  In  adults  the  differential  diagnosis 
between  the  two  diseases  could  hardly  arise,  since  grown 
people  usually  do  not  suffer  from  ringworm  of  the  scalp. 
Folliculitis  decalvans,  with  its  minute  abscesses  pierced  by 
a  hair,  followed  by  irregular,  smooth,  white,  depressed 
scars,  should  not  be  confounded  with  the  very  different 
lesions  of  alopecia  areata. 

Prognosis. — The  prognosis  in  the  mild  forms  of  alopecia 
areata  is  generally  favorable.  The  outlook  is  better  for  the 
young  than  for  the  middle-aged  or  the  old.  Recovery 
takes  place  in  most  cases  in  about  three  or  four  months; 
however,  years  may  elapse  before  a  permanent  regrowth 
of  hair  occurs.  The  prognosis  in  the  malignant  type  is  bad. 

Treatment. — In  some  cases  tonics  are  apparently  required 
internally,  especially  iron,  arsenic,  strychnine,  hypophos- 
phites.  Defects  of  the  general  health  should  be  remedied 
if  possible,  and  since  certain  authors  regard  disorders  of 
the  teeth  and  visual  abnormalities  as  possible  causative 
agents  in  alopecia  areata,  diseases  of  these  organs  should 
receive  proper  attention. 

The  local  management  is,  however,  of  the  most  impor- 
tance, and  may  be  summed  up  in  the  word  stimulation. 

Our  usual  plan  is  to  blister  the  patches  every  two  weeks 
with  acetic  cantharidal  collodion  or  canthos,  after  thor- 


ALOPECIA  ARE  AT  A  443 

ough  washing  with  soap  and  water,  and  in  the  intervals  to 
rub  in  morning  and  evening  a  lotion  consisting  of  equal 
parts  of  tincture  of  cantharides  and  glycerin.  If  there  are 
several  patches,  and  of  large  extent,  it  is  safest  to  apply  the 
vesicant  to  one  or  two  places  only  at  a  time.  After  weeks 
or  months,  as  the  case  may  be,  the  scalp  begins  to  assume 
its  normal  appearance,  and  more  downy  hairs  begin  to 
appear,  which  gradually  reach  a  normal  calibre. 

Trikresol,  as  recommended  by  McGowan,  is  a  valuable 
topical  remedy,  and  has,  to  a  degree,  taken  the  place  of  the 
cantharides  in  our  practice.  It  may  be  applied  in  a  solution 
with  equal  parts  of  alcohol,  or  in  many  instances  lightly 
brushed  on  in  its  full  strength.  For  children  the  trikresol 
should  be  employed  much  weaker.  Pure  carbolic  acid 
acts  similarly,  but  it  has  not  appeared  to  be  as  effective. 
After  the  use  of  any  of  these  vesicating  remedies,  ten  days  or 
more  should  be  allowed  to  elapse  before  their  reapplication, 
but  after  the  skin  has  become  normal,  which  takes  a  few 
days,  mild  stimulating  lotions  or  salves  may  be  employed 
in  the  interval  as  mentioned  above.  Numerous  other 
remedies  have  been  proposed.  The  following  applications 
are  to  be  noted : 

1$ — Chrysarobini gr.  xxx 

Vaselini          5j — M. 

1$ — Olei  amygdaljE  dulcis 5j 

Liq.  ammoniae  fort 5j 

Spt.  rosmarini 5y 

Olei  limonis 3j — M. 

An  ointment  of  1  scruple  of  salicylic  acid,  2  drachms  of 
sulphur,  and  1  oz.  of  vaselin  is  also  valuable,  and  may 
take  the  place  of  the  lotion  of  cantharides  and  glycerin. 

Jackson  speaks  well  of  extract  of  pilocarpus,  1  drachm 
to  1  oz.  of  sulphur  ointment. 

Sabouraud  blisters  the  patches  and  paints  the  raw  sur- 
faces with  a  solution  of  nitrate  of  silver  (1  to  15). 

Horand  has  found  croton  oil  the  most  efficacious  drug, 
and  he  does  not  think  it  dangerous. 

Moty  and  others  recommend  injections  of  bichloride  of 


444         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

mercury  into  the  patches.  The  hydrochlorate  of  pilocar- 
pine  has  also  been  advised  for  hypodermic  injection. 
Epilation  of  the  loose  hairs  should  be  carried  out  as  a 
routine  practice,  and  is  to  be  preferred  to  shaving. 

Alopecia  of  the  bearded  face  and  the  eyebrows  does  not 
admit  of  the  use  of  harsh  applications.  In  these  situations 
we  have  secured  the  best  results  in  a  medicinal  way  by 
inunctions  of  weak  sulphur  ointments,  and  especially  of  a 
preparation  advised  by  Lassar  in  general  alopecia 

1$ — Pilocarpinae  hydrochlor gr.  ix 

Quininjp  hydrochlor 9j 

Sulphuris  praecip gr.  xlv 

Balsami  peruviani gr.  xc 

Medullse  bovina?       .      .      .      .  .      .      .  5j — M. 

The  bearded  region  should  be  kept  constantly  shaved, 
not  only  to  obviate  the  contrast  between  the  bald  and  hairy 
regions,  but  as  a  valuable  method  of  obtaining  a  certain 
amount  of  local  stimulation. 

Galvanism  and  faradism  have  been  a  good  deal  employed 
in  alopecia  areata,  but  it  is  probable  that  the  high- 
frequency  current  will  be  found  much  more  efficient,  and  as 
a  matter  of  fact  this  has  been  our  experience.  E.  R.  Mor- 
ton, of  London,  has  succeeded  with  this  method  in  cases  in 
which  all  else  had  failed. 

In  the  universal  or  very  extensive  types  of  this  disease 
described  by  Michelson  as  alopecia  maligna  x-rays  have 
remained  without  avail.  In  the  more  localized  forms, 
while  uncertain  and  far  from  being  a  specific,  they  some- 
times succeed  where  other  means  do  not. 

The  use  of  the  rays  here  may  at  first  sight  seem  like  an 
application  of  homeopathic  principles.  Its  reasonable- 
ness, however,  may  be  seen  by  reference  to  the  article  on 
Effects  of  the  Rays  on  Tissues  (p.  569).  What  is  more 
strange  is  that  the  proper  dose  and  quality  of  rays,  as 
stated  by  Holzknecht  and  Kienbock,  is  the  same  as  they 
employ  to  produce  alopecia  in  the  trichomycoses  (see  p. 
453),  using  a  little  less  for  the  beard  than  for  the  scalp. 
Evidently  the  papilla  affected  with  alopecia  areata  does  not 


ALOPECIA  ARE  AT  A  445 

respond  in  the  usual  manner.  This  is  shown  by  the  course 
of  events  in  cases  successfully  treated  by  the  rays.  First, 
the  hairs  at  the  margin  fall  out.  Later,  hairs  appear  in  the 
diseased  patch,  and  last  of  all  the  healthy  marginal  hairs 
return. 

Holzknecht  pursues  one  of  two  methods.  Single  or  few 
patches  are  treated  separately,  the  rest  of  the  scalp  being 
shielded.  When,  however,  there  are  many  patches  the 
whole  scalp  is  irradiated  without  respect  to  apparently 
still  healthy  portions. 

That  the  ray  is  not  a  specific  in  this  affection  is  shown 
by  Hyde,  Montgomery,  and  Ormsby.  In  18  cases  they 
observed  prompt  return  of  the  hair  in  2,  marked  improve- 
ment in  3,  and  no  change  in  13. 

Pusey  sagely  warns  us  not  too  hurriedly  to  accept 
conclusions  as  to  the  value  of  any  remedial  measure  in  a 
disease  like  this,  in  which  rapid  recovery  often  occurs  in 
the  absence  of  all  treatment. 

Phototherapy  has  been  used  by  several  physicians  with 
satisfactory  results. 

At  the  Finsen  Institute,  one-hour  exposures  daily  are 
continued  from  one  to  eight  weeks.  Of  49  cases  treated, 
30  \vere  cured.  Sabouraud,  after  treating  40  cases  with  a 
smaller  lamp,  found  the  method  uncertain.  Kromayer 
treated  3  patients  with  his  all-iron  electrode  lamp,  all  with 
success.  Stelwagon  believes  this  lamp  to  be  sufficiently 
penetrating  for  the  purpose. 

It  would  seem  that  in  an  affection  so  generally  amenable 
to  treatment  the  simpler  therapeutic  measures  should  be 
given  preference. 

ADDITIONAL  PRESCRIPTIONS. 

1^— Alcoholis,  90  %  ...  .  3  j 

S|)t.  lavandukv •    .      .      .      5j 

&que  destfllatse 3ij 

Potassii  nitratis gr.  j 

Acidi  acetici  glaciale gr.  iv — M. 

S.— Rub  daily  into  the  patches.  Sabouraud. 


446         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

J% — Tr.  eantharidis, 

Tr.  capsici aa     3ss 

Olei  ricini 5j 

Spt.  odorati        ....      .      .      q.  s.  ad     5ij — M. 

S. — External  use.  Tilbury  Fox. 

1$ — Ol.  ricini 3ss 

Acidi  carbolici 3j 

Tr.  eantharidis 3ss 

Ol.  rosmarini gtt.  xv 

Spt.  vini  rectificat q.  s.  ad    3iv — M. 

S. — Use  with  friction.  Hyde  and  Montgomery. 

1$ — Acidi  lactici 3J-3J 

Olei  ricini      .      . oij 

Spt.  vini    •    .      .      .      .      .      .      .      q.  s.  ad    3iv — M. 

S. — To  be  applied  daily,  but  with  caution  at  first. 

Norman  Walker. 


FOLLICULITIS  DECALVANS. 

Description. — During  the  past  several  years  there  have 
been  described,  especially  in  France,  certain  classes  of 
cases  that  have,  in  common,  inflammatory  changes  in  and 
about  the  hair  follicle,  and  which  finally  result  in  permanent 
loss  of  hair  and  the  presence  of  scars,  and  exhibit  a  general 
tendency  to  agmination. 

The  regions  involved  are  preeminently  the  hairy  scalp 
and  contiguous  parts,  the  beard,  and  less  frequently  other 
parts  of  the  body.  The  following  are  some  of  the  descrip- 
tive titles  employed:  Folliculite  e*pilante,  acne*  de*pilante 
cicatricielle,  acn£  de"calvante,  lupoid  sycosis,  ulerythema 
sycosiforme,  folliculite  et  pdrifolliculite  d^calvantes  ag- 
mine'es,  etc.  It  would  be  rash  to  say  that  these  various 
disorders  are  identical  etiologically  and  pathologically, 
but,  at  least,  they  all  have  a  clinical  resemblance.  As  types 
of  these  affections  several  of  the  more  well-defined  may  be 
briefly  described: 

Simple  folliculitis  decalvans,  or  false  alopecia  areata, 
begins  as  a  folliculitis  or  perifolliculitis,  but  the  inflamma- 
tory symptoms  are  slight,  consisting  of  some  redness  and 
swelling  about  the  hair  follicles.  The  hairs  fall  out  readily 


FOLLICULITIS  DECALVANS  447 

and  are  not  replaced,  and  when  this  occurs  the  inflamma- 
tion subsides,  but  leaves  behind  atrophy  of  the  papill£e  and 
scalp.  There  is  no  pustulation.  The  patches  extend 
irregularly  and  not  by  the  gradual  increase  in  area  of  round 
or  oval  lesions  as  seen  in  true  alopecia  areata. 

Quinquad's  disease  usually  attacks  the  scalp,  but  the 
beard,  axillae  or  pubic  region  may  also  be  the  seat  of  the 
disorder.  In  these  cases  a  small  pin-head  sized  pustule  is 
pierced  by  a  hair,  the  miliary  abscess  soon  causing  loss  of 
the  hair  and  destruction  of  the  follicle. 

The  lesions  appear  in  successive  crops,  but  are  few  in 
number  and  isolated.  The  resulting  atrophic  patches  are 
irregular  in  outline,  about  the  size  of  a  twenty-five-cent 
piece,  and  scattered  here  and  there  over  the  scalp. 

Ulerythema  sycosiforme  of  Unna,  as  described  in  his 
own  words,  begins  in  the  beard  or  the  temporal  region  with 
flat,  elevated  (?),  sharply  margined,  erythematous  spots, 
on  which  appear  superficial  vesicles,  crusts,  and  scales.  It 
extends  serpiginously  with  red,  slightly  elevated  borders, 
following  the  course  of  the  beard,  and  also  attacking  the 
region  of  the  cilia  and  supercilia. 

It  is  very  chronic,  and  eventually  leads  to  the  formation 
of  hairless,  atrophic  surfaces.  The  addition  of  an  impetigo 
may  give  the  disorder  the  appearance  of  a  coccogenic 
sycosis.  The  atrophy,  according  to  Unna,  is  never  the 
result  of  suppuration,  and  the  disappearance  of  the  hair 
is  merely  a  manifestation  of  the  atrophy  of  the  whole 
epithelium. 

Treatment. — The  treatment  of  these  various  disorders 
has  not  been  satisfactorily  worked  out — in  fact,  for  the 
most  part  is  unavailing — but  on  the  whole  is,  perhaps,  in 
the  direction  of  parasiticides  and  antiseptics.  In  the  dis- 
ease bearing  his  name,  Quinquaud  prescribes  thorough 
ablution  with  soap  and  water,  and  the  daily  application  of 
a  mercurial  lotion,  viz. : 

1$ — Hydrarg.  bichloridi gr.  vj 

Hydrarg.  biniodidi         gr.  j 

Alcoholis 3vj 

Aquae  destillatae       .  ,      .  Svjss — M. 


448 


SYCOSIS. 


Description. — Sycosis  non-parasitica,  mentagra,  follicu- 
litis  barbae,  is  an  acute  or  chronic  inflammatory  disease 
affecting  the  hair  follicles,  particularly  of  the  beard,  due  to 
microbic  infection,  and  characterized  by  papules,  pustules, 
and  tubercles  perforated  by  hairs,  together  with  infiltra- 
tion of  the  skin  and  crusting. 

It  was  formerly  the  custom  to  describe  two  forms  of 
sycosis,  the  one  parasitic  and  the  other  non-parasitic;  the 
parasitic  form  being  due  to  the  inoculation  of  the  fungus 
of  ringworm.  The  bacteriological  researches  of  recent 
years  have  shown  that  both  disorders  are  parasitic,  inas- 
much as  the  affection  now  under  consideration  is  the  result 
of  infection  with  microorganisms,  the  Staphylococcus 
aureus,  citreus  or  albus,  or  other  pyogenic  germs.  Unna 
suggests  that  the  word  sycosis  be  retained,  and  the  one  be 
called  "coccogenic  sycosis"  and  the  other  "hyphogenic 
sycosis;"  and  for  still  another  clinical  form  the  term  "bacil- 
logenic  sycosis"  may  be  applied. 

Sycosis  is  mostly  developed  on  the  bearded  portion  of 
the  face,  but  it  may  be  found  on  other  parts  of  the  body 
supplied  with  hair,  e.  g.,  the  eyebrows,  axilla* ,  pubes,  the 
vibrissse,  etc. ;  even  on  the  hairy  part  of  the  face  it  may  be 
limited  to  the  upper  lip,  or  to  small  patches  elsewhere. 
The  disease  may  commence  by  the  appearance  of  a  few 
papules  and  pustules  perforated  by  hairs,  there  being  pres- 
ent at  the  same  time  a  certain  amount  of  heat  and  swelling 
of  the  parts.  At  other  times  an  erythematous  or  moist 
eczema  has  preceded  the  eruption.  Sycosis  of  the  upper 
lip  is  commonly  set  up  by  the  discharge  from  a  chronic 
nasal  catarrh.  When  the  affection  sets  in  acutely  the  local 
symptoms  may  be  quite  severe,  consisting  of  great  heat  of 
the  surface,  considerable  pain,  tumefaction  of  the  skin, 
and  even  enlargement  of  the  contiguous  lymphatic  glands. 
The  lesions  in  the  beginning  of  acute  outbreaks  usually 
appear  in  considerable  numbers  and  close  together,  but  in 


SYCOSIS  449 

cases  that  have  begun  insidiously  they  are  not  so  numerous 
and  are  discrete.  In  regions  where  the  beard  is  thick,  and 
which  have  been  repeatedly  attacked,  considerable  infil- 
trations may  be  observed,  involving  wide  areas.  It  does 
not  follow,  however,  that  the  disease  always  relapses  in  the 
same  locality.  The  acneiform  papules  and  tubercles  soon 
become  converted  into  pustules.  The  characteristic  feat- 
ure of  sycosis  is  that  each  papule,  tubercle,  and  pustule  is 
pierced  by  a  hair.  During  the  papular  stage  extraction  of 
the  hairs  causes  considerable  pain,  but  afterward,  when 
suppuration  has  occurred,  they  may  be  readily  and  pain- 
lessly plucked  from  the  follicle.  The  pus  dries  up  into  thin, 
brownish-yellow  crusts,  which  upon  removal  will  exhibit 
hairs  seated  in  a  shallow  pit  bathed  in  pus.  More  or  less 
scarring  and  permanent  alopecia  results,  and  sometimes, 
in  severe  cases,  the  destruction  of  the  tissues  and  glandu- 
lar apparatus  is  very  extensive.  The  diseased  process  is 
strictly  limited  to  regions  covered  by  hair,  and  does  not 
step  out  of  those  boundaries. 

Sycosis  is  a  chronic  affection,  usually  lasting  months  or 
even  years,  being  kept  up  by  relapses  at  irregular  periods. 
According  to  Robinson,  sycosis  is  primarily  a  perifollicular 
inflammation,  the  first  changes  occurring  around  the  follicle 
in  the  perifollicular  region.  Later  the  follicle  and  its 
sheath  become  implicated.  Scratching  and  free  sweating 
are  factors  in  its  production  under  the  armpits,  and  it  is 
quite  often  secondary  to  scratching  upon  the  pubes  and 
labia. 

Lupoid  sycosis  (Milton)  is  considered  by  some  authors 
as  identical  with  Unna's  ulerythema  sycosiforme,  but  Unna 
himself  does  not  regard  this  latter  affection  as  a  coccogenic 
sycosis  at  all,  but  as  a  true  ulerythema  (q.  v.}. 

It  is  a  commonly  accepted  opinion  that  sycosis  is  the 
result,  directly  or  indirectly,  of  the  invasion  of  the  follicle 
by  pus  organisms,  the  same  pyococci  that  cause  furuncle 
and  impetigo  (Bockhart).  Robinson  states  that  his  own 
investigations  demonstrated  the  presence  of  the  Staphy- 
lococcus  pyogenes  aureus  as  well  as  cereus  and  albus;  but 
29 


450         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

he  declares,  further,  that  the  direct  exciting  agent  may  not 
in  all  cases  be  a  pus  organism,  but  some  of  the  agents  that 
produce  ordinary  papular  or  vesicular  eczema,  and  pus 
organisms  finding  a  favorable  soil  form  a  complicating 
factor.  It  is  more  than  likely,  as  has  also  been  urged,  that 
there  exists  a  number  of  predisposing  conditions  that 
render  the  soil  more  susceptible  to  infection,  such  as  nutri- 
tive disturbances  of  one  sort  or  another,  special  cutaneous 
vulnerability,  acrid  discharges,  as  from  the  nose,  etc.  It 
was  formerly  declared  that  sycosis  was  not  contagious, 
but,  aside  from  theoretical  preconceptions,  we  are  quite 
confident  that  the  disease  is  often  conveyed  through  the 
medium  of  infected  brushes,  strops,  towels  and  fingers,  in 
barber  shops. 

Diagnosis. — Sycosis  must  not  be  confounded  with  eczema 
(q.  v.)  and  tinea  sycosis.  As  regards  the  latter  disease,  in 
doubtful  cases,  the  microscope  will  settle  the  question. 

Prognosis. — The  prognosis  should  be  very  guarded,  as 
the  disease  is  exceedingly  obstinate  and  very  prone  to 
relapse;  besides,  being  on  the  face,  it  is  a  very  difficult 
matter  to  secure  the  cooperation  of  the  patient  in  the 
matter  of  wearing  salves,  shaving,  etc.  However,  as 
regards  a  particular  outbreak  of  the  disease,  a  cure  may 
be  promised  under  certain  reservations. 

Treatment. — Internal  treatment,  unless  obviously  de- 
manded by  other  considerations,  is  altogether  unneces- 
sary. If  a  nasal  discharge  is  responsible  for  a  sycosis  of  the 
upper  lip,  it  will  be  necessary  to  stop  the  discharge  before 
the  sycosis  can  be  cured.  In  the  acute  stages  of  the  disease 
soothing  measures  are  required : 

1$ — Olei  amygdala*  dulcis 3ij 

Liq.  ruin's 3ij 

Acidi  carbolic! ,      .     n^v-x — M 

1^ — Zinci  oxidi 3ss 

Pulv.  acacia- oj 

Emuls.  amygdalae 3ij 

Aquae  rosee q.  s.  ad  3iv — M. 

Olive  or  almond  oil,  lead  lotion,  and  the  black  wash, 
followed  by  zinc  ointment,  are  all  useful  for  the  purpose. 


SYCOSIS  451 

The  hair  should  be  closely  cut,  and  if  crusts  have  formed 
they  must  be  first  removed  by  inunctions  with  oil  or  hot 
poultices  before  the  appropriate  remedies  are  applied. 
Usually,  when  the  patient  comes  under  the  care  of  a 
dermatologist,  the  disorder  has  reached  a  more  chronic 
stage.  It  is  at  this  time  that  shaving  and  epilation  become 
indispensable  parts  of  the  treatment. 

The  beard  should  be  shaved  at  least  every  second  day, 
the  crusts  having  been  first  removed,  and  the  hairs  epilated 
from  all  pustules.  The  patient  will  always  demur  to  the 
shaving,  having  an  idea,  also  shared  by  the  barber,  that 
the  operation  is  impossible.  A  little  firmness  on  the  part 
of  the  physician  will  usually  carry  the  point. 

It  is  a  matter  of  considerable  importance  to  discard  the 
shaving  brush,  for  if  it  is  not  thoroughly  disinfected  after 
use  it  is  qui+e  possible  to  keep  up  the  infection  in  this  way. 
It  is  safer  to  employ  the  shaving  creams,  which  may  be 
rubbed  in  with  the  fingers.  After  shaving,  or  after  epila- 
tion, the  skin  should  be  fomented  for  awhile  with  very  hot 
water  to  relieve  the  congestion,  and  while  this  is  being 
accomplished  a  soothing  and  somewhat  astringent  ointment 
such  as  the  unguentum  vaselini  plumbicum  should  be 
applied,  spread  on  strips  of  cotton  and  neatly  bound  on  the 
affected  surface.  Robinson  thinks  well  of  the  following 
combination : 

1$ — Ung.  diachylon, 

Fng.  zinci  oxidi aa   3jss 

Ung.  hydrarg.  ammon.  chlor 3iij 

Bismuthi  subnitratis ojss — M. 

When  the  disease  has  become  veritably  chronic,  more 
energetic  measures  still  are  advisable.  While  in  the  acute 
stage  epilation  should  be  practised  only  on  hairs  connected 
with  pustules,  it  is  now  proper  to  pull  them  both  from 
papules  and  pustules.  To  relieve  the  infiltration  of  the 
skin,  rubbing  with  green  soap,  or  the  tincture  of  green 
soap,  as  in  eczema,  immediately  followed  by  diachylon 
ointment,  gives  good  results.  Sulphur  and  the  various 
mercurial  preparations  are  also  to  be  recommended.  The 


452         AFFECTIONS  OF  THE  HAIR  FOLLICLES 

following   preparation,  conjoined  with  shaving   and  epi- 
lation,  has  served  a  good  purpose: 

1$ — Acidi  salicylic! 9j 

Suphuris  praecipitati 3ij 

Ung.  aquae  rosae 5j — M. 

S. — Rub  in  thoroughly  twice  a  day. 

We  have  found  Rosen thal's  paste,  slightly  modified,  of 
extreme  value: 

Ifc — Acidi  tannici gr.  Ixxv 

Sulphuris  praecipitati 3ijss 

Zinci  oxidi, 

Pulv.  amyli aa  oiij 

Vaselini  .  3ijss — M. 

S  — Apply,  quite  thinly,  twice  a  day. 

This  preparation,  as  well  as  Lassar's  paste,  is  useful  in 
axillary  and  pubic  sycosis  and  other  hairy  regions  on  the 
trunk  or  legs.  The  frequent  folliculitis  of  the  back  of  the 
neck,  which  is  mainly  acquired  at  the  barber  shop,  may  be 
treated  with  boric  acid  solutions  frequently  applied,  but 
above  all  by  insisting  upon  strict  antisepsis  on  the  part  of 
the  barber.  Vleminckx's  solution  used  in  the  same  manner 
as  in  acne  is  also  a  useful  application  in  this  locality. 

Some  authorities  recommend  going  rough-shod  over 
the  affected  parts  with  the  dermal  curette,  following  the 
operation  with  some  emollient  oil  or  ointment.  After 
recovery  the  shaving  of  the  beard  should  be  kept  up,  at 
least  for  a  long  period,  and  if  the  skin  is  dry,  red,  and  scaly, 
this  condition  may  be  benefited  by  using  a  salve  of  lanolin 
and  cold  cream. 

Ichthyol  in  the  strength  of  ^  to  2  drachms  to  1  oz.  of 
excipient  is  recommended  by  Stelwagon  in  sycosis  generally. 
Ehrmann  suggests,  as  of  practical  value,  a  10  per  cent, 
solution  of  pyoktanin  introduced  into  the  follicles  by 
cataphoresis. 

In  the  treatment  of  this  condition  by  the  x-rays  we  must 
bear  in  mind  that  we  are  dealing  with  a  highly  susceptible 
region,  the  irritability  of  which  is  enhanced  by  the  fact 
that  it  is  already  inflamed.  While  epilation  is  the  most 


SYCOSIS  453 

important  part  of  the  treatment,  it  is  not  all.  Particularly 
does  this  observation  apply  to  such  cases  as  we  see  in  our 
clinics,  presenting  dense  infiltration  and  deep-seated 
pockets  of  pus.  As  Belot  well  says:  "No  one  has  ever 
claimed  for  the  x-rays  the  faculty  of  absorbing  an  abscess, 
or  of  taking  the  place  of  a  bistoury."  In  the  milder  grades 
of  the  disease,  such  as  occur  in  American  private  practice, 
the  rays  alone  may  effect  a  cure.  Inasmuch,  however,  as 
it  does  not  destroy  the  pus  germs  left  in  the  follicles,  and 
that  these  often  infect  the  new  hairs,  we  may  be  obliged, 
as  with  other  methods  of  epilation,  to  work  several  times 
over  the  whole  surface.  In  doing  so,  however,  we  court 
the  risk  of  a  permanent  alopecia.  In  the  worst  cases, 
such  a  resuk  is  the  best  solution  of  the  difficulty.  But 
even  in  milder  grades  the  ar-rays  present  this  advantage 
over  other  epilating  methods,  namely,  that  the  alopecia 
so  produced  is  of  longer  duration  and,  therefore,  affords 
more  time  for  the  follicle  to  return  to  the  normal. 

Even  in  the  deep,  suppurative  cases,  however,  Freund 
induces  a  notable  amelioration  in  the  inflammatory  phenom- 
ena by  a  small  number  of  exposures  with  a  hard  tube. 
Holzknecht  and  Kienbock  adopt  nearly  identical  methods. 
The  latter,  in  cases  involving  the  whole  bearded  region, 
divides  it  into  four  areas:  the  lips,  the  chin,  and  one  for 
each  cheek.  The  non-hairy  portions,  including  the  ver- 
milion of  the  lips,  are  carefully  shielded.  3  to  5  H.  are 
given  at  one  sitting,  with  a  safe  tube  distance.  Depila- 
tion  begins  in  a  week,  with  increased  inflammation,  dis- 
charge of  small  perifollicular  abscesses,  and,  later,  healing. 
When,  about  six  weeks  later,  the  beard  reappears,  shaving 
should  be  commenced  and  continued  for  many  months,  or, 
as  Holzknecht  says,  a  year  or  more.  This  is  good  practice 
after  any  method  of  cure. 

Stelwagon  gives  ten  or  twelve  exposures  at  two  or  three 
days'  interval,  beginning  with  five  minutes  at  ten  inches, 
and  using  a  soft  to  medium  tube. 

Allen  found  phototherapy  of  use. 


454  DISEASES  OF  THE  NAILS 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Sulphuris  pnecipitati 5j 

Balsami  peruviani  3j 

Ung.  diachyli 3vj — M. 

S. — External  use.  Stelwagon. 

1$ — Hydrarg.  oleatis  (2%%) 5j 

Ammon.  sulph.  ichthyolici rr\xx 

Acidi  salicylic! gr.  x 

Olei  lavandulae gtt.  ij — M. 

S. — Apply  on  strips  of  muslin.  Brooke. 

1$ — Hydrarg.  sulph.  rubri  .      .••'..      .  •    .      .      .  gr.  vij 

Sulphuris  sublimati 5ij 

Adipis 3J88 

Ol.  bergamottse q.  s. — M. 

S. — To  be  kept  on  constantly.  Lassar. 

1$ — Xeroformi gr/xv 

Vaselini 3ij 

Lanolini 5vj — M. 

S. — To  be  applied  in  subacute  conditions. 


DISEASES  OF  THE  NAILS. 
ONYCHAUXIS. 

Description. — Onychauxis  is  synonymous  with  incrcax d 
growth  or  hypertrophy  of  the  nails.  Onychauxis  may  exist 
in  many  degrees  and  varieties  of  thickness  and  deformity, 
a  simple  keratoma  without  other  change,  or,  as  generally 
happens,  associated  with  alteration  in  texture,  color,  and 
shape.  When  the  growth  is  chiefly  forward  the  nail  becomes 
bent  and  twisted,  sometimes  spirally,  like  a  ram's  horn. 

In  this  condition,  known  as  onychogryphosis,  the  nail 
is  much  thickened,  strongly  ridged  both  transversely  and 
longitudinally,  shining,  but  more  or  less  discolored,  of  a 
yellow  or  brownish  hue. 


ONYCHAUXIS  455 

Onychauxis  may  occur  in  the  nails  of  the  fingers  or  toes. 
It  is  generally  limited  to  the  toes,  especially  the  great  toe, 
and  is  rarely  seen  on  the  fingers.  The  process  is  a  non- 
inflammatory one,  though  the  encroachment  of  the  greatly 
thickened  nail  upon  the  soft  parts  laterally  may  occasion- 
ally set  up  a  paronychia.  Atrophic  conditions  may  also 
coexist. 

Gross  neglect  of  the  care  of  the  nails,  whereby  irritative 
processes,  with  consecutive  hypertrophy,  are  induced,  is 
not  an  uncommon  cause.  In  many  cases  met  with  in 
practice,  various  symptomatic  factors  are  to  be  recognized. 
A  hyperplasia  of  the  nail  cells  occasionally  occurs  in  con- 
nection with  various  affections  of  the  nervous  system,  e.  g., 
chronic  myelitis,  neuralgia,  etc. 

Hypertrophy  of  the  nail  also  accompanies  psoriasis, 
pityriasis  rubra  of  Hebra,  pityriasis  rubra  pilaris,  eczema, 
ichthyosis,  syphilis,  and  occurs  as  a  result  of  the  invasion 
of  the  vegetable  parasites. 

Unna,  under  the  name  scleronychia,  has  described  a 
condition  in  which  the  nails  are  thickened,  inelastic,  hard, 
rough,  and  of  a  yellowish-gray  color,  with  disappearance 
of  the  lunula. 

Treatment. — The  treatment  of  onychauxis  resolves  itself 
into  the  correction  of  the  traumatic  influences,  that  is  to 
say,  relief  from  the  pressure  of  ill-fitting  shoes,  cleanliness, 
care  of  the  nails,  necessary  internal  medication  where 
systemic  diseases  are  at  work,  and  the  appropriate  remedies 
where  inflammatory  diseases  have  excited  hyperplasia. 
An  important  point  is  the  protection  of  the  soft  parts. 

Surgical  procedures,  even  to  the  point  of  removal  of  the 
nail  and  scraping  the  nail  bed  by  means  of  the  sharp 
spoon,  are  occasionally  demanded. 

Certain  hypertrophic  conditions  of  the  nail  associated 
with  eczema,  psoriasis,  etc.,  may  be  satisfactorily  treated 
with  the  ar-rays. 


456  DISEASES  OF  THE  NAILS 


ONYCHIA. 

Description. — This  is  a  term  usually  employed  to  denote 
inflammation  of  the  matrix  of  the  nail.  The  expressions 
paronychia,  etc.,  usually  indicate  the  degree  and  extent  of 
the  inflammatory  condition  present. 

The  most  frequent  causes  are  traumatic  lesions,  with 
consequent  entrance  of  pus  organisms,  syphilis,  leprosy, 
eczema,  tuberculosis,  impetigo  contagiosa,  and  the  fungous 
disorders. 

One  of  the  most  frequent  of  the  inflammatory  affections 
of  the  nail  is  that  called  unguis  incarnatus,  or  ingrowing 
nail.  The  great  toe,  at  its  outer  nail  border,  is  most 
frequently  aft'ected.  Traumatism,  the  result  of  ill-fitting 
shoes,  is  the  most  frequent  cause.  Moreover,  a  greater  or 
less  degree  of  inflammation  is  sometimes  observed  about 
the  finger-nails,  constituting  what  is  known  to  the  laity 
as  a  "run-around." 

Treatment. — In  mild  cases  of  onychia,  Stelwagon  advises 
frequent  washing  of  the  parts  with  saturated  solution  of 
boric  acid  and  the  continuous  application  of  a  25  or  50 
per  cent,  ichthyol  ointment.  He  also  advises  painting 
both  around  and  under  the  edges  of  the  nail  with  a  2  to  5 
per  cent,  solution  of  nitrate  of  silver  in  sweet  spirits  of 
nitre. 

Jackson  employs,  in  traumatic  onychia,  a  10  to  20  per 
cent,  ointment  of  resorcin,  or  directs  that  the  parts  be 
painted  with  the  tincture  of  iodine. 

In  our  own  experience,  there  is  nothing  so  valuable  in 
the  ordinary  forms  of  onychia  and  so-called  paronychial 
inflammation  as  a  10  per  cent,  ointment  of  xeroform. 

1$ — Xeroformi gr.  xlviij 

Vaselini 5ij 

Lanolini 3vj — M. 

S. — Spread  on  patent  lint  and  apply  to  parts. 

In  certain  cases  where  the  inflammation  creeps  slowly 
around  the  nail  border,  the  skin  may  be  gently  pushed  back 


ONYCHIA  457 

and  the  xeroform  in  powder  form  insinuated  under  the 
fold,  the  whole  being  covered  with  the  ointment  just  men- 
tioned. In  acute  onychia  accompanied  by  intense  pain 
of  a  throbbing  character,  division  of  the  nail  will  give  the 
speediest  relief.  In  the  phlegmonous  variety  it  is  usually 
necessary  to  remove  the  nail  and  then  dress  the  parts  with 
xeroform  or  the  powdered  nitrate  of  lead. 

Where  there  is  a  suspicion  of  tuberculous  infection, 
Shield  insists  upon  the  free  use  of  the  curette  followed  by 
the  application  of  pure  carbolic  acid.  In  the  strumous 
and  syphilitic  appropriate  internal  treatment  is  required. 

The  treatment  of  ingrowing  nail  is  mainly  surgical,  but 
occasionally  relief  may  be  obtained  by  simpler  means.  The 
principal  thing  is  the  removal  of  pressure  by  wearing 
properly  built  shoes,  and  when  this  end  has  been  secured 
the  restoration  of  the  axis  of  the  nail  bed  and  nail 
plate  (Unna).  This  may  often  be  effected  by  introduc- 
ing some  substance  like  sponge,  lint,  tin-foil,  etc.,  between 
the  nail  and  furrow.  The  size  of  the  wedge  may  be 
gradually  increased.  Should  ulceration  and  granulation 
be  present,  the  sponge  wedge,  if  that  has  been  selected,  is 
saturated  with  a  2  per  cent,  alcoholic  solution  of  nitrate  of 
silver. 

Kaposi  speaks  very  positively  of  the  value  of  placing 
fibers  of  lint,  the  length  of  the  nail  fold,  between  the  fold 
and  the  edge  of  the  nail,  after  which  soap  plaster  is  wound 
around  in  circular  slips,  thus  securing  the  threads  and 
drawing  the  fold  away  from  the  nail.  A  method  of  treat- 
ment advised  by  Kinsman  is  as  follows:  After  removing 
all  pressure  from  the  nail  by  cutting  away  the  shoe,  the 
ulcerated  parts  are  thoroughly  disinfected  with  hydrogen 
dioxide;  then  one  drop  of  cocaine  solution  is  applied, 
followed  by  one  drop  of  Monsel's  solution,  after  which  the 
toe  is  covered  over  loosely  with  gauze.  The  process  is  to 
be  repeated  every  second  day  until  the  nail  is  released  by 
the  retraction  of  the  tissues. 

Puerckhauer's  method  is  said  to  be  satisfactory,  being 
both  bloodless  and  painless.  The  nail  is  moistened  with 


458  DISEASES  OF  THE  NAILS 

warm  40  per  cent,  solution  of  caustic  potash,  and  in  a  few 
seconds,  as  the  surface  becomes  soft,  it  is  scraped  with  a 
piece  of  glass,  after  which  the  solution  is  again  applied 
and  the  scraping  repeated  until  the  portion  of  the  nail  to  be 
removed  is  as  thin  as  paper,  when  it  can  be  lifted  up  with 
forceps  and  readily  cut  with  scissors. 


ONYCHOMYCOSIS 

Description. — Onychomycosis  is  a  disease  of  the  nail 
produced  by  fungi.  The  fungi  which  invade  the  nail 
are  Tinea  favosa  (favus)  and  Tinea  trichophytina  (ring- 
worm). One  or  more  nails  may  be  affected  with  these 
disorders,  the  disease  beginning  in  the  nail  bed  and 
affecting  the  matrix  secondarily,  only  rarely.  The  nail 
becomes  more  or  less  thickened,  its  texture  is  less  dense, 
the  surface  loses  its  lustre,  discoloration  of  a  dull,  yellowish 
hue  ensues,  and  the  surface  may  be  more  or  less  irregular 
from  imperfect  growth,  and  is  furrowed  and  pitted  in 
various  ways. 

Treatment. — For  the  treatment  of  these  affections  see  the 
sections  on  Ringworm  and  Favus. 


ATROPHIA  UNGUIUM. 

Description. — Atrophy  of  the  nail  may  be  either  a  con- 
genital or  acquired  condition.  In  the  congenital  form 
various  grades  of  defective  growth,  even  to  entire  absence 
of  the  nail,  will  be  observed.  The  acquired  atrophies  of 
the  nail  result,  for  the  most  part,  from  general  or  local 
disturbances  of  nutrition,  as,  on  the  one  hand,  syphilis 
and  cachectic  states  generally,  and,  on  the  other  hand, 
changes  consecutive  to  eczema,  psoriasis,  parasitic  affec- 
tions, etc.  Traumatisms  of  different  kinds  effect  retro- 
gressive degenerations  in  the  nail  plate.  The  most 
marked  instance  of  thinning  and  softening  is  seen  in 


ATROPHIA   UNGUIUM  459 

pemphigus  foliaceus.  Several  neurotic  conditions,  e.  g.t 
neuritis,  leprosy,  and  syphilis  of  the  nervous  system,  are 
not  infrequent  causes  of  atrophy.  The  nails  may  become 
thinned  and  softened,  or  brittle  and  crumbling.  Furrow- 
ing, discoloration,  and  a  pitted  or  worm-eaten  appearance 
and  white  spots,  are  also  common  symptoms. 

Leucopathia  unguium,  or  white  nails,  is  a  term  used  to 
describe  the  white  spots  or  bands  commonly  seen  upon  the 
nails.  They  are  due  either  to  general  nutritional  disturb- 
ances, to  nervous  affections,  or  traumatisms. 

Treatment. — The  general  treatment  will  depend  upon  the 
causative  factors  involved,  when  these  can  be  ascertained. 
Empirically,  arsenic  may  be  given  with  some  hope  of 
benefit  in  most  dystrophies  of  the  nails,  but  its  use  must 
be  long  continued.  Lactophosphate  of  lime  and  sulphur, 
the  latter  in  the  form  of  Garrod's  lozenges,  are  also  undoubt- 
edly of  some  value.  Locally,  the  parts  should  be  protected 
by  rubber  finger-stalls,  the  wax  finger,  or  other  suitable 
means.  Discontinuance  of  the  manicure  operations  will 
often  stop  the  production  of  the  white  spots  often  seen  on 
the  nails  of  young  women. 


PAEASITIC  DISEASES. 


VEGETABLE  PARASITIC  AFFECTIONS. 
FAVUS. 

Description. — Tinea  favosa,  or  favus,  is  a  contagious 
disease,  produced  by  the  Achorion  Schoenleinii,  which  is 
usually,  although  not  invariably,  confined  to  the  scalp, 
and  presents  peculiar,  variously  sized,  sulphur-yellow, 
cup-like  crusts  pierced  by  hairs. 

It  is  comparatively  rare  in  this  country. 

The  disease  may  attack  any  part  of  the  body,  even,  in 
very  rare  instances,  the  mucous  membrances  of  the  stomach 
and  bowels,  but  it  has  a  predilection  for  the  scalp.  In  the 
first  stages,  which,  however,  the  physician  rarely  witnesses, 
there  arise  erythematous  patches  attended  by  some  itching 
and  desquamation,  and  after  a  season  there  will  develop  the 
characteristic  sulphur-yellow,  umbilicated  favus  cups.  As 
ordinarily  encountered  on  the  scalp,  a  somewhat  complex 
clinical  picture  is  presented,  in  which  the  observer  will 
notice  the  lustreless  state  of  the  hairs,  the  masses  of  yellow 
crusts,  and  irregular  areas  of  baldness,  and  detect  a  peculiar, 
musty  odor  arising  from  the  diseased  surface.  Studied 
somewhat  more  in  detail  the  following  features  are  to  be 
noted:  In  the  beginning  the  favus  crusts,  which  lie 
beneath  the  epidermis,  are  pin-head  in  size,  pierced  by  a 
hair,  and  of  sulphur-yellow  color;  they  grow  quickly, 
however,  and  soon  attain  the  dimensions  of  a  split  pea;  at 
the  same  time,  according  to  Kaposi,  the  peripheral  portion 
of  the  epidermis  projects,  but  the  part  surrounding  the 
hair  remains  on  a  level  or  else  sinks  slightly,  thus  pro- 
ducing the  likeness  to  a  little  cup.  The  developed  crusts 


FAVU&  461 

rise  a  line  or  more  above  the  skin,  are  round  or  oval  in 
outline,  and  are  made  up  of  several  concentrically  dis- 
posed strata ;  they  are  very  friable,  being  readily  crumpled 
between  the  fingers. 

When,  at  an  early  stage,  a  crust  is  picked  off  the  scalp, 
a  slight  depression,  which  soon  fills  out,  may  be  observed ; 
but  later  the  underlying  part  will  be  found  dry  and  atro- 
phied, or  sometimes  the  seat  of  suppuration.  The  lesions 
are  at  first  discrete,  but,  as  a  rule,  they  finally  run  together 
to  form  dirty-grayish,  mortar-like  masses  with  a  more  or 
less  irregular  outline. 

The  hair  becomes  dry,  brittle,  and  without  lustre,  as  a 
result  of  the  parasitic  invasion ;  the  follicles  are  eventually 
destroyed,  and  permanent  alopecia  results. 

Sometimes  no  cups  are  present,  but  the  scalp  exhibits 
patches  of  a  chronic,  scaly  redness;  in  other  instances, 
according  to  Sabouraud,  there  is  an  impetiginous  form 
with  honey-like  crusts.  Occasionally  the  disease  is  met 
with  on  the  general  surface  of  the  body — tinea  favosa 
epidermidis,  and  the  parasite  also  invades  the  nails. 

Etiology. — Favus  occurs  mostly  among  the  poor  and 
ill-nourished,  and  attacks  children  more  frequently  than 
adults.  It  also  is  found  on  the  lower  animals,  mice,  cats, 
etc.,  and  the  contagion  in  some  instances  proceeds  from 
these  sources.  While  favus  is  a  contagious  disease,  cer- 
tain favorable  conditions  of  soil  seem  to  be  required  for  its 
ready  reception.  The  direct  cause  of  favus  is  the  pres- 
ence of  the  vegetable  parasite  known  as  the  Achorion 
Schoenleinii.  The  fungus  invades  the  epidermis,  especially 
the  horny  layer,  the  hair  follicles,  and  the  hair. 

It  has  been  claimed  by  some  observers  that  there  are 
different  forms  of  the  fungus,  in  some  instances  corre- 
sponding to  different  varieties  of  the  disease,  but  this 
opinion  is  not  general. 

Diagnosis. — Favus  is  usually  readily  recognized.  The 
yellow  masses,  made  up  of  saucer-like  crusts,  the  irregular 
bald  areas,  and  the  stale  odor  are  characteristic.  In  eases 
just  beginning,  or  in  cases  where  the  favus  crusts  have 


462  PARASITIC  DISEASES 

run  together  to  form  mortary  masses,  it  is  sometimes 
necessary  to  suspend  judgment  for  awhile.  It  is  essential 
to  distinguish  favus  from  ringworm,  eczema,  psoriasis, 
seborrhea,  and  lupus  erythematosus.  In  all  suspicious 
cases  the  microscope  should  be  appealed  to,  which,  taken 
in  connection  with  the  clinical  history,  will  generally  estab- 
lish the  diagnosis. 

Prognosis. — Untreated,  the  disease  lasts  for  years,  leaving 
in  its  wake  marked  disfigurement  of  the  parts  in  the  shape 
of  scars  and  bald  patches.  Under  the  most  favorable  cir- 
cumstances favus  is  an  intractable  disorder.  A  period  of 
treatment  averaging  from  four  to  twelve  months  may  be 
expected  under  the  older  methods,  and  even  after  an 
apparent  cure  the  patient  should  be  inspected  from  time 
to  time,  to  make  sure  of  the  permanency  of  the  results. 

Treatment. — The  treatment  of  favus  is  entirely  local, 
although  tonics  and  nutritious  food  are  helpful  adjuncts. 
Stelwagon  believes  that  sulphur  in  from  3-  to  10-gr.  doses, 
three  times  a  day,  has  some  influence  on  the  disease. 
When  the  affection  is  seated  on  the  scalp  the  first  'thing  to 
be  attended  to  is  the  removal  of  the  crusts.  After  clipping 
the  hair  short  the  parts  may  be  soaked  in  oil  or  poulticed, 
and  subsequently  washed  with  soap  and  hot  water.  The 
crusts  having  been  removed,  the  next  step  is  the  removal 
of  the  hairs.  Various  plans  of  epilation  have  been  sug- 
gested, such  as  Bulkley's  epilating  sticks,  etc.,  but  the 
simplest  and  surest  is  with  the  broad  epilating  forceps, 
and  the  easiest  with  the  o>rays.  The  pain  of  the  former 
process  may  be  lessened  by  rubbing  in  a  tolerably  strong 
solution  of  carbolic  acid.  French  writers  advocate  extend- 
ing the  epilation  somewhat  beyond  the  border  of  the  affected 
area.  A  small  amount  of  surface  may  be  attacked  at  a 
time  and  the  parasiticide  applied  at  once. 

The  remedies  that  have  been  recommended  in  the  treat- 
ment are  very  numerous,  but  we  can  mention  only  a 
few  of  the  approved  methods.  Among  the  antiparasitic 
remedies  most  employed  are  tar,  sulphur,  carbolic  acid, 
chrysarobin,  pyrogallol,  salicylic  acid,  sulphurous  acid, 


FAVUS  463 

and  the  mercurials.     Bichloride  of  mercury  dissolved  in 
ether  or  alcohol  has  given  fair  results : 

1^ — Hydrarg.  bichloridi gr.  j-ij 

Alcoholis §j — M. 

S. — Apply  immediately  after  epilation,  and  twice  a  day  thereafter. 

Jamieson  states  that  he  has  used  Ihle's  paste  without 
epilation  with  much  satisfaction : 

1^ — Resorcini 3j-3jss 

Lanolini, 

Vaselini, 

Zinci  oxidi, 

Pulv.  amyli aa     5ij — M. 

The  hair  is  kept  short,  the  head  washed  daily  with  soft 
soap,  and  the  paste  applied  immediately  after  the  head  is 
dry. 

In  the  mean  time,  for  the  purpose  of  preventing  the  dis- 
semination of  the  disease,  the  whole  scalp  should  be  treated 
with  a  saturated  solution  of  boric  acid  or  a  carbolic  acid 
lotion  of  the  strength  of  2  to  4  drachms  to  1  pint.  After 
a  season  the  treatment  may  be  suspended  to  judge  of  the 
results  obtained.  If  the  disorder  reappears  the  same 
procedure  must  be  repeated. 

An  old  formula  of  Pirogoff's  has  been  recently  reintro- 
duced : 

1$ — Sulphuris  sublimati 3ss 

Potassii  carbonatis .  5j 

Picis  liquidip 5jss 

Tr.  iodi 3jss 

Adipis 3iij — M. 

The  head  is  shaved  and  a  cloth  smeared  with  this  salve 
is  applied  for  twenty-four  hours.  At  the  end  of  this  time 
the  crusts  are  removed  and  the  scalp  washed.  The  appli- 
cations are  repeated  every  twenty-four  hours  until  active 
desquamation  occurs,  when  inflammation  is  allayed  by  a 
soothing  paste.  Whatever  method  is  employed  in  the 
treatment  of  favus,  whether  distinctly  parasiticidal,  irri- 
tative, or  mechanical,  the  object  sought  is  to  remove  the 
fungus,  and  to  accomplish  this  end  requires  minute  atten- 
tion to  detail  and  unflagging  patience. 

What  will  be  said  more  fully  in  the  next  section  of  the 


464  PARASITIC  DISEASES 

use  of  the  x-rays  in  tinea  might  be  said  in  this  place,  except 
that  it  is  not  here  so  great  a  boon,  since  epilation  by  the 
older  methods  is  much  more  efficient  in  favus  than  in  tinea, 
for  the  reason  that  the  hair-shaft  in  the  former  disease  not 
being  infiltrated,  it  comes  out  whole  upon  traction.  Besides, 
thorough  epilation  is  less  efficient  in  favus  than  in  tinea, 
as  the  fungus  in  the  latter  invades  the  follicle  walls  and  is, 
therefore,  left  behind.  The  ray  must,  therefore,  be  sup- 
plemented by  the  use  of  antiseptics,  thoroughly  rubbed  in 
after  all  signs  of  reaction  have  ceased.  On  account  of 
the  danger  of  reinfection,  Torok,  Schein,  Holzknecht, 
Kienbock,  and  Freund  all  advise  epilation  of  the  entire  scalp, 
the  latter  recommending  as  an  antiseptic,  a  strong  phenol- 
lanolin,  this  drug  being  more  inimical  to  the  achorion  than 
the  iodine  recommended  by  Sabouraud  in  ringworm. 

Kienbock  epilates  the  entire  scalp  at  one  sitting,  dividing 
it  into  six  areas,  which  are  successively  irradiated  for  a 
period  of  five  to  eight  minutes  each  with  an  absorption  of 
4  or  5  H. 

Sabouraud  says:  "  Both  diseases  (ringworm  and  favus  of 
the  scalp)  are  amenable  to  the  same  treatment,  which  lasts 
a  few  weeks  only,  in  place  of  the  years  required  under  the 
old  method." 

Epidermic  favus  should  be  treated  by  the  usual  parasiti- 
cides. Painting  with  tincture  of  iodine,  or  the  application 
of  a  weak  bichloride  solution  dissolved  in  collodion  is 
generally  efficacious.  In  favus  of  the  nail,  in  addition  to  the 
application  of  the  parasiticide,  the  diseased  portion  should 
be  pared  away. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Cerse  flavse 5ij 

Laccae  in  tabulis 5iv 

Picis  burgundicse 5x 

Gummi  clamar 5jss — M. 

S. — Melt  together  and  mold  into  sticks  for  epilating. 

Bulkley. 

1$ — Resorcini 3j 

(.)!.  amygdal.  dulcis oij 

Lanolini 3vj — M. 

S. — External  use.  Crocker. 


RINGWORM  465 

1$ — Acidi  carbolic! 3j 

Ung.  picis  liq., 

Ung.  hydrarg.  nitratis aa    3ij 

Ung.  sulphuris   .  3iv— M. 

S. — An  ointment  for  the  scalp.      Make  up  freshly  once  a  week. 

Stel  wagon. 

1$ — Chrysarobini, 

Ichthyolis aa   gr.  Ixxv 

Acidi  salicylici gr.  xlv 

Vaselini .    giij — M. 

S. — External  use.  Unna. 

RINGWORM. 

Up  to  within  a  comparatively  recent  period  it  was 
believed  that  ringworm  in  its  various  manifestations  was 
due  to  a  special  fungus,  the  Trichophyton  tonsurans,  and  that 
the  clinical  differences  were  the  result  of  variations  in 
regard  to  the  luxuriance  of  its  growth  and  the  susceptibility 
of  the  skin,  the  point  of  attack,  etc.  It  is  impossible  here 
to  enter  at  all  minutely  into  this  question,  but  it  suffices  to 
say  that  since  Sabouraud's  researches  in  1894,  the  plurality 
of  the  fungi  in  ringworm  has  been  very  generally  admitted. 
He  declares  that  the  ringworm  encountered  in  human 
subjects  comprises  two  affections  caused  by  fungi  as  dis- 
tinct from  each  other  in  every  way  as  those  of  favus  or 
tinea  versicolor.  The  following  divisions  are  now  usually 
recognized : 

1.  Tinea  of  Gruby  and  Sabouraud,  or  common  tinea; 
tinea  with  small  spores  due  to  the  Microsporon  audouini. 

2.  Trichophytic  tinea,  or  tinea  with  large  spores  due  to 
the  various  forms  of  Trichophyton  megalosporon. 

There  are  two  varieties  of  the  large-spored  fungus,  the 
endothrix  and  the  ectothrix,  which  are  again  divided  into 
several  subspecies. 

Ringworm  exhibits  considerable  diversity  of  clinical 
appearance  according  to  the  parts  attacked,  and,  as  is  now 
taught,  the  lesional  expression  will  vary  according  to  the 
species  of  fungus  present.  Necessarily,  also,  the  matter  of 
treatment  will  in  a  measure  depend  upon  the  part  of  the 
body  invaded. 
30 


466  PARASITIC  DISEASES 

Ringworm  of  the  Scalp.  Description. — Since  the  dem- 
onstration of  the  plurality  of  the  fungi  in  ringworm  was 
established,  it  has  been  shown  that  the  clinical  appearances 
will  depend  upon  the  source  of  the  infection.  In  ringworm 
of  the  scalp  due  to  the  small-spore  tinea  (Microsporon 
audouini)  there  may  be  one  or  several  patches,  varying  in 
size,  round  or  oval  and  distinctly  circumscribed.  Some- 
times there  is  one  large  patch  with  outlying  satellites.  In 
young  children  there  may  be  a  hyperemic  ring  at  the 
circumference.  The  mouths  of  the  follicles  are  sometimes 
slightly  raised,  making  the  lesion  look  like  the  skin  of  a 
plucked  fowl.  The  patches  are  not  bald,  but  covered  with 
stumps  about  one-eighth  inch  in  length,  the  stumps  being 
surrounded  at  their  bases  by  whitish  sheaths  or  collarettes, 
which,  lying  close  together  over  the  diseased  areas,  give  the 
skin  its  powdery  aspect.  The  hairs  are  pale  and  lustre- 
less, usually  lie  all  in  one  direction,  and  readily  break  off, 
and  as  the  majority  of  hairs  are  affected,  the  patch  has 
the  appearance  of  a  cornfield  covered  with  the  stubble  of 
broken,  bent,  and  frayed -out  stalks.  The  patch  or  patches 
may  be  scaly  or  not,  but  the  skin  is  usually  unaltered 
unless  there  is  a  complicating  seborrhea. 

Aldersmith  states  that,  quite  rarely,  he  has  seen  the 
places  get  quite  bald,  even  with  club-shaped  stumps,  closely 
simulating  alopecia  areata.  Sometimes  there  is  a  certain 
amount  of  eczema  with  crusting  of  a  seborrheal  type. 
Contrary  to  Sabouraud's  original  -statement,  several 
authorities  state  that  the  small-spore  tinea  may,  excep- 
tionally, cause  pustules  and  even  the  kerion  type.  The 
microsporon  may  also  produce  small,  scaly  places  on  the 
body,  that  is,  the  neck,  face,  and  shoulders,  and  also  red, 
raised  rings  about  three-quarters  of  an  inch  in  diameter  or 
even  larger  (Adamson).  The  majority  of  cases  of  ring- 
worm of  the  scalp  observed  in  this  country  are  due  to  the 
small-spore  fungus. 

Large-spore  tinea  of  the  endothrix  variety  produces  on 
the  scalp  certain  appearances  that  differ  somewhat  from 
the  conditions  just  described.  The  skin  in  the  affected 


RINGWORM  467 

areas  is  usually  cleaner  and  smoother,  and  it  is  said  that 
the  patches  are  smaller. 

Black-dot  ringworm  in  which  the  hairs  are  broken  off  at 
the  mouth  of  the  follicle,  and  in  which  the  patches  suggest 
alopecia  areata,  is  due  to  the  endothrix  fungus. 

The  ectothrix  produces,  as  a  rule,  single  lesions,  though 
from  auto-inoculation  others  will  form  later  on.  The  clini- 
cal characters  are  diverse,  such  as  dermatitis,  impetigo, 
folliculitis,  discrete  or  conglomerate,  kerion,  etc.  There 
may  be  swollen  glands  and  some  febrile  reaction.  Ac- 
cording to  Fox  and  Blaxall  the  hairs  are  less  eroded  and 
broken  up  than  in  other  forms,  and  it  is  sometimes  diffi- 
cult to  detect  an  obviously  diseased  stump,  or  even  traces 
of  the  fungus. 

Kerion  is  really  an  acute  folliculitis  in  which  arises  a 
circumscribed,  boggy  swelling  studded  over  with  gaping 
follicles  that  pour  out  a  sticky,  honey-like  secretion.  Sup- 
puration is  exceedingly  rare,  but  the  hairs  fall  out  and  leave 
exposed  a  red  patch  that  after  awhile  becomes  normal. 
Sabouraud  holds  that  this  condition  is  always  due  to  the 
ectothrix  fungus,  but  the  English  authorities  state  that  it 
also  occurs  with  the  microsporon. 

Diagnosis. — The  essential  feature  in  the  diagnosis  of 
tinea  tonsurans  is  the  discovery  of  scaly,  circular  patches 
on  the  scalp  in  which  the  hairs  are  broken  off,  dry,  brittle, 
and  variously  distorted.  Even  in  the  disseminated  cases 
the  stumps  are  usually  sufficiently  characteristic.  How- 
ever, as  all  cases  are  unfortunately  not  typical,  it  will  be 
found  that  the  following  diseases  sometimes  simulate  ring- 
worm, viz.,  eczema,  seborrhea,  psoriasis,  alopecia  areata, 
and  certain  pustular  affections. 

In  all  doubtful  cases  the  mfcroscope  should  be  brought 
into  requisition.  For  purposes  of  examination  the  scales 
or  hairs  may  be  moistened  with  liquor  potassa?  and 
observed  with  a  power  of  from  300  to  500  diameters. 

Prognosis. — The  prognosis  will  naturally  depend  in  a 
degree  upon  the  extent  and  chronicity  of  the  ringworm, 
as  well  as  upon  the  variety  of  fungus  present  in  a  given  case. 


468  PARASITIC  DISEASES 

Until  recently,  a  cure  was  not  to  be  expected  in  new  cases 
in  less  than  two  to  four  months ;  while  in  chronic  cases, 
from  one  to  two  years  was  usually  required.  With  the 
modern  application  of  the  x-rays,  however,  the  time 
demanded  is  far  more  brief,  even  should  we  fall  short  of 
the  brilliant  results  reported  by  our  Parisian  confreres. 

Treatment. — The  physician's  first  duty  is  to  prevent  the 
spread  of  the  disease  to  others.  He  should  insist  on  exam- 
ining the  other  children  in  the  family.  If  the  case  be  in  a 
boarding  school  or  asylum,  all  inmates  should  have  their 
scalps  carefully  investigated  without  reckoning  time  or 
trouble;  isolated  stumps  and  suspicious  scaly  places 
receiving  special  attention.  It  is  not  necessary  to  isolate 
infected  children,  but  their  scalps  should  be  covered  with 
closely  fitting  caps  lined  with  paraffin  paper,  which  should 
be  changed  daily.  It  is  wrong  to  allow  ringworm  patients 
to  attend  school.  As  a  matter  of  course  combs,  brushes, 
towels,  etc.,  are  not  to  be  used  in  common,  and  should  be 
frequently  disinfected.  The  disease  in  the  beginning, 
before  the  hairs  have  become  seriously  affected,  is  more 
easily  manageable.  In  all  cases,  however,  as  a  preliminary 
step,  it  is  necessary  to  cut  or  shave  the  hair,  and  to  clear  it 
of  scales  by  washing  with  hot  water  and  soap,  preferably 
the  prepared  olive  soap  already  mentioned.  When  there 
are  but  few  patches,  especially  with  girls,  it  is  only  neces- 
sary to  clip  the  hair  for  a  space  round  about  the  affected 
area.  To  prevent  dissemination  of  the  disease  to  other 
parts  the  whole  scalp  may  be  sponged  daily  with  a  2  per 
cent,  solution  of  carbolic  acid,  a  saturated  solution  of 
boric  acid,  or,  as  recommended  by  Crocker,  carbolized 
oil,  1  in  20.  Thin  thinks  well  of  a  boric  acid  ointment 
for  this  purpose. 

It  seems  to  us  that  there  is  no  objection  to  washing  the 
scalp  every  few  days  with  soap  and  hot  water,  although 
this  practice  is  condemned  by  some  practitioners.  Morris, 
for  example,  says  that  water  should  not  be  used,  but  that 
antiseptic  washes  are  permissible.  For  this  purpose  he 
advises  a  lotion  of  10  gr.  of  salicylic  acid  to  1  oz.  of  ether 


RINGWORM  469 

or  chloroform.  There  is  also  considerable  difference  of 
opinion  as  to  the  value  of  epilation,  but  it  must  be  admitted 
that  the  practice  is  insisted  upon  by  physicians  of  the 
highest  authority. 

Aldersmith  recommends  epilation  if  the  ringworm  be 
recent,  and  if  there  be  only  a  few  places.  It  is  also  espe- 
cially useful,  he  states,  in  the  Megalosporon  endothrix, 
resistant  variety,  and  in  the  ectothrix  form.  Morris  ad- 
vises that  not  only  the  visibly  diseased  hairs  be  removed, 
but  that  a  ring  of  sound  hair  around  the  patch  should  be 
plucked  out. 

The  immediate  medicinal  treatment  consists  in  the  local 
application  of  various  substances,  combined  in  a  variety 
of  ways,  and  of  strengths  suitable  to  the  case  in  hand. 
Unfortunately  for  the  practitioner  of  little  experience  in 
ringworm,  the  number  of  agents  employed  is  so  great  that 
a  choice  of  remedies  becomes  a  matter  of  considerable 
difficulty.  Although  in  ringworm  of  the  scalp  it  is  always 
best  to  select  a  given  remedy  and  persevere  with  its  appli- 
cation, it  must  be  borne  in  mind  that  all  cases  cannot  be 
treated  alike,  and  it  will  be  convenient  to  have  at  command 
more  than  one  resource.  The  remedy  employed  must  be 
selected  with  reference  to  the  age  of  the  patient,  the  stage 
of  the  disease,  and  also  to  its  dissemination  on  the  scalp. 

In  young  children,  that  is,  under  a  year,  the  disease  will 
generally  yield  to  an  ointment  of  sulphur  of  the  strength 
of  1  drachm  to  1  oz.  of  lanolin,  lard,  or  vaselin. 

1^ — Sulphuris  pra>cipitati 5j 

Ung.  aqvur  rosse 5ij 

Lanolini 5vj — M. 

S. — Apply  night  and  morning. 

Recent  cases  occurring  in  older  children  may  often  be 
quickly  cured  by  more  decided  stimulating  remedies. 

English  physicians  speak  highly  of  Coster's  paint  (2 
drachms  of  iodine  and  5  drachms  of  colorless  oil  of  wood 
tar).  It  may  be  painted  on  with  a  stiff  brush  every  four 
or  five  days.  Simple  painting  with  the  tincture  of  iodine 
and  blistering  with  the  acetic  cantharidal  collodion  are  also 


470  PARASITIC  DISEASES 

useful.  In  more  chronic  ringworm,  the  oleate  of  copper, 
varying  in  strength  from  ^  drachm  to  4  drachms  to  1  oz., 
is  very  serviceable  (Shoemaker,  Weir). 

Salicylic  acid,  from  1  scruple  to  1  drachm,  and  sulphur 
from  1  to  2  drachms  to  1  oz.,  make  a  valuable  combination. 
The  oleate  of  mercury,  5  to  20  per  cent.,  and  carbolic  acid, 
20  to  GO  gr.  to  1  oz.  of  glycerin,  or  in  ointment,  are  to  be 
recommended.  Bichloride  of  mercury,  2  to  4  gr.  to  1  oz., 
if  used  cautiously  and  not  over  too  large  a  surface,  is  one 
of  the  most  efficacious  remedies. 

All  of  the  mercurial  preparations  do  good,  such  as  the 
citrine  ointment,  the  white  precipitate  ointment,  etc. 

Chrysarobin  is  regarded  by  Duhring,  Morris,  Stelwagon, 
and  others  as  one  of  the  most  valuable  agents  in  the  treat- 
ment of  ringworm.  It  may  be  employed  as  an  ointment  in 
strength  varying  from  10  gr.  to  2  drachms  to  1  oz.  of 
excipient.  It  must  be  applied  with  great  caution,  since  it  is 
capable  of  setting  up  a  severe  dermatitis.  Care  must  be 
taken  to  wipe  off  the  excess,  and  to  have  the  patch  pro- 
tected with  rubber  tissue  held  in  place  by  a  cap.  Hutch- 
inson  recommends  the  following  formula: 

^  —  Chrysarobini       .........  3j 

Hydrarg.  ammoniati     .......  gr.  xx 

Liq.  carbonis  deterg  ........  rr^x 

Lanolini  ...........  5j 

Adi  pis  recentis  .........  3vj  —  M. 

Unna  combines  it  with  ichthyol  and  salicylic  acid: 

1^  —  Chrysarobini       .........      gr.  Ixxv 

Acidi  salicylici    .........      3ss 


Ung.  simplicis    . 

»-  •  • 
3iij—  M. 

-Chrysarobini 
Acidi  salicylici    . 
Olei  amygdalae  . 
Lanolini  ..... 

gr.  xx-3j 
gr.  xx-3j 

q.  s.  ad      5j  —  M. 
Aldersmith. 

Chrysarobin  dissolved  in  chloroform  (Aldersmith)  or 
made  into  a  paint  with  traumaticine  or  collodion  (Alex- 
ander) is  sometimes  successful.  Cavafy's  lotion  is  made 
as  follows: 


RIXGWORM  471 

1$ — Acidi  borici 3j 

^Etheris  sulphuric! 3j 

Alcoholis giv — M. 

S. — Rub  in  with  a  sponge  two  or  three  times  a  day.  Wash  the 
head  daily  with  warm  water  and  soap. 

Aldersmith  says  that  salicylic  acid  is  an  excellent  remedy 
both  for  small  spots  and  extensive  forms  of  ringworm. 

1$ — Acidi  salicylici gr.  x-xxx 

^theris oij 

Spiritum  rectificatum ad     3j — M. 

Salicylic  acid  may  be  also  combined  with  sulphur. 

1$ — Acidi  salicylici .      .  9j 

Sulphuris  prapcipitati 3jss 

Vaselini 3j 

Olei  limonis q.  s. — M. 

The  following  method  recommended  by  Crocker  has 
given  good  results  in  our  hands.  The  patches,  as  well  as  a 
surrounding  strip  one-half  inch  wide,  are  closely  shaven, 
after  which  they  are  painted  with  collodion  containing 
salicylic  acid,  1  to  30.  Fresh  collodion  is  applied  every  day 
for  a  week.  The  dried  collodion  is  then  lifted  off  by  insert- 
ing a  spatula  under  its  edge,  and  the  process  repeated 
until  a  cure  is  effected. 

Startin's  ointment,  quoted  by  Duhring,  is  often  very 
useful. 

1$ — Sulphuris  sublimati 3ss 

Hydrarg.  ammoniati gr.  x 

Hydrarg.  sulphureti  nigri gr.  x 

Misce  et  adde : 

Oleum  olivse 5ij 

Creosotum gtt.  iv 

Adipem 3vj — M. 

In  very  rebellious  patches  the  surface  may  be  painted 
occasionally,  the  effect  being  watched,  writh  glacial  acetic 
acid,  employing  in  the  intervals  a  mild  parasiticide  like 
sulphur  ointment.  Another  form  of  treatment  for  invet- 
erate cases  is  by  the  use  of  croton  oil.  This  method  has 
both  friends  and  enemies.  Thin  and  many  others  condemn 
it  outright,  while  Aldersmith,  its  especial  advocate,  and 


472  PARASITIC  DISEASES 

Cottle  and  Crocker  look  upon  this  procedure,  when  properly 
done  in  selected  cases,  as  of  considerable  value.  Crocker's 
opinion  on  this  question  is  of  especial  importance.  This 
conservative  and  experienced  observer  says  that  the  croton- 
oil  treatment  is  a  certain  method  for  chronic  cases  of 
limited  extent,  and  for  the  isolated  diseased  hairs  and  those 
in  small  groups  in  disseminated  ringworm.  Croton  oil 
should  not  be  applied  in  the  cases  of  scrofulous  children, 
or  in  those  under  six  years  of  age.  In  limited  patches 
Crocker  makes  use  of  a  liniment  of  1  part  of  croton  oil  to 
10  of  olive  oil.  While  there  may  be  some  question  as  to 
the  advisability  of  using  the  croton  oil  over  even  so  limited 
an  area  as  one-half  square  inch,  we  can  see  no  objection 
to  its  employment  in  those  cases  displaying  isolated  stumps 
and  black  dots  here  and  there  over  the  scalp.  For  this 
purpose  one  drop  of  oil  may  be  introduced  into  the  follicle 
by  means  of  a  specially  devised  needle.  In  a  short  while  a 
pustule  forms  and  the  hair  comes  away.1 

Electrolysis  of  single  follicles  is  of  especial  value,  but 
it  must  be  remembered  that  these  destructive  methods 
produce  alopecia,  and  consequently  are  only  indicated  for 
isolated  stumps. 

Judging  from  the  recent  expressions  of  opinion  on  the 
subject,  the  treatment  of  ringworm  by  formalin  is  not  to 
be  recommended.  It  is  very  painful  and  causes  considerable 
local  reaction. 

The  condition  known  as  kerion  requires  only  a  soothing 
treatment,  which  may  be  made  mildly  antiparasitic.  The 
tumor  should  not  be  opened,  however  suggestive  of  abscess 
it  may  be. 

The  treatment  of  ringworm  should  be  kept  up  as  long 
as  there  are  any  clinical  evidences  of  the  disease  apparent, 
viz.,  the  presence  of  characteristic  stumps  and  abnormal 
desquamation ;  but  this  sort  of  evidence  must  be  supple- 
mented from  time  to  time  by  microscopic  examination. 

1  For  details  in  the  use  of  this  method  see  Aldersmith's  valuable 
treatise  on  ringworm.  He  still  maintains  its  great  value  in  suitable 
cases  if  done  with  proper  precautions. 


RINGWORM  473 

The  value  of  the  x-rays  for  the  production  of  epilation  in 
parasitic  disease  rests  on  quite  other  grounds  than  is  the 
case  in  hypertrichosis,  for  here  we  neither  need  nor  desire 
a  permanent  alopecia,  and,  therefore,  do  not  push  the 
treatment  to  the  point  of  producing  atrophy.  Besides, 
while  the  epilating  effects  of  the  rays  on  the  face  are  slow 
and  disappointing,  on  the  scalp,  a  region  oftener  attacked 
by  the  trichomycoses,  they  are  rapid  and  satisfactory.  It 
has  long  been  recognized  that  epilation  is  the  sine  qua  non 
of  success  in  the  treatment  of  these  diseases.  Not  only, 
however,  was  the  process  slow  and  painful  by  all  former 
methods,  but  often  ineffectual,  inasmuch  as  a  portion  of  the 
spore-laden  hair  was  left  behind  in  the  follicle.  In  the 
x-rays  we  have  at  last  the  desired  agent — painless,  rapid, 
and  efficient. 

We  must  be  careful,  however,  not  to  overstep  the  mark 
and  produce  a  permanent  alopecia.  Sabouraud  gives  a 
simple  formula:  tube  distance,  6  inches;  penetration,  No. 
4,  Benoist;  quantity,  4  or  5  H;  one  sitting  of  twenty-five 
minutes'  duration.  The  equivalent  spark  with  a  coil  is 
only  2|  cm.  long.  Depilation  begins  fifteen  to  twenty  days 
later.  If  there  are  several  patches,  the  above  dosage  is  to 
be  applied  to  each  one.  Where  the  whole  or  a  large  part  of 
the  scalp  is  involved,  the  matter  becomes  more  complicated, 
as  it  is  essential  to  leave  no  hairs  between  the  areas  separ- 
ately treated.  These  hairs  would  soon  reinfect  the  portions 
cured.  Of  course,  in  the  latter  class  of  cases  the  treatment 
must  be  prolonged  over  several  or  many  sittings.  If  there 
be  no  more  than  five  patches,  each  patch  is  painted  with 
tincture  of  iodine,  going  1  cm.  beyond  the  diseased  area, 
and  separately  treated.  If  the  number  of  patches  be 
greater,  the  whole  scalp  is  divided  into  6  parts  and  each 
separately  treated.  In  any  case  all  parts  not  immediately 
under  treatment  are  carefully  shielded.  After  exposure 
Sabouraud  uses  daily  washing  with  soap,  followed  by  fric- 
tion of  the  whole  scalp  with  a  mixture  of  1  part  tincture  of 
iodine  to  5  of  alcohol.  This  not  only  helps  in  dislodging 
loosened  hairs,  but  serves  to  prevent  reinfection.  The 


474  PARASITIC  DISEASES 

danger  of  this  accident  lies  in  the  fact  that  the  spores  in  the 
cast-off  hairs  retain  their  full  activity,  the  beneficent  action 
of  the  rays  being  limited  to  dislodging  the  hair  unbroken 
from  its  follicle.  One  sitting  generally  suffices  to  a  cure 
of  a  single  patch. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Hydrarg.  ipdidi  rubri    . gr.  iv-vj 

Sodii  iodidi 5ss 

Spt.  chloroform! 3ij-  3iv 

Aquam  ad 5j — M. 

S. — To  be  applied  to  small  places.  Aldersmith. 

1$ — Sulphur,  sublimat gr.  iij 

Acidi  carbolici m.  xx 

Lanolini, 

Olei  olivae aa     3ij — M. 

Morris. 

1$ — Sulphuris  prsecipitati 3j 

Hydrarg.  ammoniati 3ss 

Thymolis gr.  x 

Vaselini 3j 

Ung.  simplicis q.   s.  ad     5j — M. 

S. — Dissolve  the  thymol  in  the  vaselin  by  aid  of  heat. 

Jamieson. 

1^ — Sulphuris  prsecip 3j-5jss 

Acidi  salicylici gr.  xv-xxx 

Adipem  benzoatum ad      5  j — M. 

S. — To  be  rubbed  in  over  the  whole  scalp  once  a  day  directly  after 
washing.  Some  stronger  parasiticide  to  be  applied  to  the  patches. 

Aldersmith. 

Ringworm  of  the  Body,  or  Tinea  Circinata.  Descrip- 
tion.— The  common  sites  of  eruption  are  the  face,  neck,  and 
the  backs  of  the  hands,  although  other  parts  are  not  infre- 
quently affected.  As  stated  above,  it  is  not  uncommon  to 
find  small,  scaly  patches  on  the  necks  and  faces  of  chil- 
dren suffering  from  the  small-spore  ringworm  of  the  scalp. 
In  another  variety  of  the  disease  due  either  to  the  endo- 
thrix  or  microsporon  fungus  the  first  evidence  of  the  dis- 
order is  a  scaly,  erythematous  spot  that  spreads  periph- 
erally. The  outer  raised  border  is  usually  papular  and 
shows  more  desquamation  than  the  centre  of  the  patch. 


RINGWORM  475 

Meantime  the  lesion  goes  on  increasing  in  size,  sometimes 
to  the  diameter  of  a  silver  dollar,  or  even  of  the  palm  of  the 
hand,  but  simultaneously  the  patch  clears  up  in  the  middle, 
and  in  this  way  ring-forms  are  produced.  In  some  instances 
the  margins  of  the  patches  are  distinctly  papular  or  vesi- 
cular. When  several  rings  are  situated  near  each  other 
they  may  join  and  in  this  manner  give  rise  to  irregular 
gyrate  lines;  or,  rarely,  several  rings,  one  within  the  other, 
may  be  developed. 

At  times,  ringworm  of  the  body  occurs  as  merely  scaly, 
generally  rounded,  eczematous-1  coking  patches. 

The  fungus  is  sometimes  found  on  the  palms  and  soles, 
and  may  also  invade  the  mucous  outlets.  The  nails  may 
be  invaded  by  the  parasite,  becoming  brittle,  opaque,  and 
often  longitudinally  furrowed. 

When  the  fungus  finds  a  lodgement  in  parts  of  the  body 
where  skin  surfaces  are  in  contact,  the  concomitant  con- 
ditions of  heat  and  moisture  seem  to  furnish  more  favorable 
soil  for  its  growth,  and  as  a  consequence  the  symptoms  that 
are  set  up  are  more  violent  and  obstinate.  Under  these 
circumstances  the  disease  is  encountered  in  the  axillae,  and 
more  especially  on  the  thigh,  where,  owing  to  the  char- 
acters that  it  assumed,  the  disorder  was  called  eczema 
marginatum  by  Hebra.  From  the  latter  situation  it  may 
spread  to  some  extent  down  the  thighs  and  over  the  buttocks, 
and  lower  part  of  the  abdomen.  Although  the  parts  may 
look  as  if  affected  by  an  ordinary  eczema,  the  outer  border 
will  be  abrupt,  papular,  sometimes  vesicular  and  clearly 
defined  against  the  outlying  skin. 

It  is  now  recognized  that  the  affection  called  "agmi- 
nate folliculitis"  is  in  reality  ringworm.  The  lesions, 
which  consist  of  raised  patches  of  various  sizes,  studded 
with  small  pustules,  are  red  and  edematous,  and  attended 
with  some  itching  and  burning.  In  other  types  the  dis- 
turbance is  more  profound,  and  resembles  in  a  measure  a 
kerion  of  the  scalp.  The  forearm,  back  of  the  hand,  and 
the  buttocks  are  said  to  be  the  usual  sites  of  attack.  This 
form  is  due  to  the  ectothrix  fungus  and  is  of  animal 
origin. 


476  PARASITIC  DISEASES 

Diagnosis. — It  is  not  always  an  easy  matter  to  demon- 
strate the  trichophyton  microscopically.  For  this  purpose 
a  few  scales  may  be  taken  from  the  periphery  of  a  patch 
and  moistened  with  liquor  potassce,  and  under  a  power  of 
several  hundred  diameters,  both  mycelia  and  spores  may  be 
detected,  but  as  a  rule  in  scant  quantity.  The  clinical 
diagnosis  is  more  immediately  important. 

It  is  to  be  distinguished  from  syphilis,  eczema,  psoriasis, 
and  seborrhea. 

Prognosis. — The  prognosis  is  favorable.  Eczema  mar- 
ginatum  is  somewhat  more  obstinate,  but  a  satisfactory 
result  may  be  obtained  with  the  exercise  of  ordinary 
patience  and  skill. 

Treatment. — The  treatment  for  ringworm  of  the  general 
surface  is  usually  simple  and  effectual.  A  few  paintings 
with  tincture  of  iodine,  after  washing  with  soap  and  water, 
will  often  suffice.  Among  other  remedies  may  be  men- 
tioned an  ointment  of  salicylic  acid  (20  gr.)  and  sulphur 
(1  drachm  to  1  oz.  of  vaselin;  white  precipitate,  30  or  40 
gr.  to  1  oz. ;  corrosive  sublimate,  2  gr.  to  1  oz.  of  water  or 
alcohol;  hyposulphite  of  sodium,  60  gr.  to  1  oz.  of  vaselin 
or  water) ;  in  fact,  any  of  the  usual  parasiticides.  In  the 
so-called  eczema  marginatum,  Taylor  recommends  2  to  4 
gr.  of  corrosive  sublimate  to  1  oz.  of  tincture  of  benzoin. 
Bulkley  extols  the  fresh  sulphurous  acid.  In  obstinate 
cases  modified  Wilkinson's  ointment  is  quite  valuable. 
Rosenthal's  paste  is  also  useful.  We  think  it  is  better  to 
avoid  chrysarobin  preparations  in  this  locality  for  fear  of 
undue  irritation.  After  proper  scraping  and  paring,  similar 
remedies  may  be  applied  to  the  nails  when  affected. 

Dubreuilh  in  onychomycosis  smears  the  nails  twice  daily 
with  equal  parts  of  pyrogallic  acid  and  olive  oil.  It  pro- 
duces acute  inflammation  and  the  discharge  of  the  nail. 
Sabouraud  uses  a  solution  of  iodine,  15  gr.;  potassium 
iodide,  30  gr. ;  water,  1  quart.  Absorbent  cotton  is  soaked 
in  this  solution  and  applied  to  the  nails  under  a  rubber 
stall.  It  is  certainly  a  more  agreeable  method  than  the 
production  of  a  paronychia. 


RINGWORM  477 

Harrison's  method  is  highly  recommended  by  British 
writers.  The  nail  is  first  scraped  and  then  solution  No.  1 
(1^ — Liq.  potassse,  aquae,  aa  §ss;  potassii  iodidi,  3ss)  is 
applied  by  means  of  lint  covered  with  oiled  silk,  and 
allowed  to  remain  in  place  fifteen  minutes;  then  solution 
No.  2  (1$ — Hydrarg.  bichlor.,  gr.  iv;  alcoholis,  aquae,  aa 
§ss)  is  immediately  put  on,  following  the  same  procedure, 
and  allowed  to  remain  in  place  for  twenty-four  hours. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Creosoti n\xx 

Olei  cadini, 

Sulphuris  sublimati aa     3iij 

Potassii  bicarb 5j 

Adipis 5j — M. 

S. — External  use.  Tilbury  Fox. 

1$ — Resorcini •  «  .  gr.  x-xv 

Sulphur,  prsecip., 

Zinci  oxidi aa  3ss 

Vaselini 5j — M. 

S. — For  ringworm  of  the  general  surface. 

]$ — Acidi  salicylici gr.  xx 

Collodiiflex 5j— M. 

S. — Paint  on  eruption. 

1$ — Hydrarg.  ammoniati gr.  iij 

Adipis 5j — M. 

S. — Local  use.    For  young  children.  Morris. 

Ringworm  of  the  Beard.  Description. — Tinea  barbse, 
tinea  sycosis,  sycosis  parasitica,  barber's  itch,  or  ringworm 
of  the  beard  is  a  form  of  acute  inflammation  of  the  hair 
follicles  of  the  hairy  parts  of  the  face  or  neck,  and  is 
due  according  to  Sabouraud  to  the  ectothrix  fungus. 

Tinea  sycosis  begins  much  in  the  same  way  that  a  ring- 
worm does  elsewhere,  that  is  to  say,  as  a  reddish,  circular, 
slightly  scaly,  and  somewhat  itchy  patch.  Such  a  patch 
may  be  flat  or  raised  at  the  outer  border,  and  occasionally 
show  a  few  papules  or  vesicopustules.  One  or  more 
lesions  may  be  present.  This  superficial  form  of  the 
disorder  is  the  more  common,  and  differs  but  little  in 


478  PARASITIC  DISEASES 

appearance  from  tinea  tonsurans.  The  moustache  is  rarely 
invaded,  but  the  chin,  submaxillary  regions,  and  the  neck 
are  usually  affected. 

Sometimes  the  mild  or  pityriasic  form  spontaneously 
recovers,  or  is  readily  cured,  the  soil  being  unfavorable  to 
the  growth  of  the  fungus;  but  under  other  circumstances, 
in  untreated,  neglected  or  particularly  susceptible  cases, 
or,  perhaps,  from  the  nature  of  the  fungus  itself,  the  disease 
extends,  the  parasite  attacks  the  follicles,  with  the  result 
of  inducing  follicular  and  perifollicular  inflammation, 
and  the  consequent  formation  of  deep-seated  nodules, 
that  often  run  together  to  make  more  or  less  extensive, 
lumpy  patches.  Much  pain  and  burning  is  often  experi- 
enced, especially  in  acutely  developed  cases,  and  the  parts 
present  a  deep-red  or  purple  appearance. 

The  hairs  either  fall  out  over  the  affected  areas  or  may 
be  extracted  with  great  ease,  and  from  the  follicular  open- 
ing a  mucoid  secretion  is  poured  out,  as  in  kerion.  Often 
pustulation  is  a  marked  feature,  and  numerous  crusts  form, 
which  upon  removal  exhibit  an  uneven,  raspberry-like  sur- 
face. One  or  more  nodules  may  be  present,  or  occupy  cir- 
cumscribed regions,  or  the  whole  surface  of  the  neck  and 
chin  may  be  invaded.  Permanent  alopecia  may  result  from 
destruction  of  the  hair  follicle.  The  disease  is  apt  to  pur- 
sue a  chronic  course. 

Sabouraud  insists  that  the  parasite  is  always  of  animal 
origin.  As  the  disease  is  less  frequent  in  men  who  wear 
beards  or  shave  themselves,  it  is  likely  that  the  barber 
and  his  utensils  are,  to  a  certain  extent,  carriers  of  the 
infection.  Aldersmith  says  that  he  has  never  known  the 
fathers  of  children  with  common  scalp  ringworm  to  get 
parasitic  sycosis  from  them.  Bulkley,  on  the  other  hand, 
states  that  clinical  experience  shows  that  this  disease  is 
constantly  contracted  from,  and  again  produces  in  others, 
the  ordinary  forms  of  ringworm  of  the  body  and  scalp. 

Diagnosis. — The  characteristic  features  of  the  disease- 
are,  in  the  mild  form,  the  presence  of  one  or  more  circular, 
scaly  patches  in  the  region  of  the  beard,  with  or  without  a 


RINGWORM  479 

raised  margin,  which  sometimes  clear  in  the  centre,  leaving 
a  ringed  border;  in  the  severe  form  there  occur  acute 
folliculitis,  indurated  nodules,  and  brawny,  deep-seated 
infiltrations  from  which  the  hairs  have  fallen  out  or  may  be 
painlessly  extracted,  showing,  besides,  either  a  crusted 
surface  or  exhibiting  a  sticky,  mucoid  secretion.  Tinea 
sycosis  is  to  be  differentiated  from  simple  sycosis,  eczema, 
and  certain  forms  of  syphilis.  In  all  cases  of  doubt  micro- 
scopic examinations  should  be  made. 

Prognosis. — Untreated  cases  run  on  indefinitely;  but, 
if  promptly  and  energetically  treated,  a  favorable  result 
may  be  expected;  in  fact,  it  is  a  much  more  tractable 
affection  than  ringworm  of  the  scalp. 

Treatment. — In  the  early  and  superficial  stage,  the 
disease  may  be  cured  without  great  difficulty.  Often  the 
application  of  the  sulphur  and  salicylic  acid  ointment, 
or  an  ointment  of  white  precipitate  (30  gr.)  and  the  liquor 
carbonis  detergens,  1  drachm  to  1  oz.,  is  quite  sufficient. 
A  more  elegant  and  cleanly  method  is  the  application 
of  the  bichloride  of  mercury  (2  to  4  gr.)  in  1  oz.  of 
tincture  of  benzoin  (Taylor)  or  the  same  in  water  or 
alcohol.  Ihle  praises  resorcin  (!$ — Resorcini,  3ijss>  vase- 
lini,  5jss;  zinci  oxidi,  amyli,  fiii  3vj — M.). 

In  the  deep  or  kerion-like  form  it  is  necessary  to  remove 
crusts,  to  shave,  and,  as  the  hairs  are  readily  extracted,  to 
epilate.  The  crusts  are  best  removed  by  applying  the 
unguentum  vaselini  plumbicum  spread  on  cloths,  which 
also,  at  the  same  time,  soothes  the  inflamed  surfaces. 
Although,  as  a  rule,  it  is  altogether  unnecessary  to  open 
the  nodules,  occasionally  much  comfort  is  secured  by  free 
incisions.  After  the  acuteness  of  the  attack  has  worn 
away  somewhat,  it  is  advisable  to  begin  the  use  of  para- 
siticides. Sulphur  and  tar,  mercury,  sulphur  and  salicylic 
acid,  the  oleate  of  copper,  and  the  hyposulphite  of  sodium 
in  ointment  or  lotion  are  all  efficient: 

1$ — Sodii  hyposulphitis oiv 

AqiiM'  aeatfllatee 5iv — M. 

S. — Mop  on  affected  parts  three  or  four  times  a  day. 


480  PARASITIC  DISEASES 

1$ — Acidi  carbolic! 9j 

Sulphuris  praecipitati 3j 

Vaselini 5J— M. 

S. — Apply  twice  a  day. 

Shaving  should  be  kept  up  daily,  or  at  any  rate  every 
other  day,  for  some  months  after  appa'  ent  cure. 

The  x-ray  treatment  is  similar  to  that  used  in  tinea 
tonsurans,  except  that  one  need  proceed  with  more  caution. 
A  raying  which  would  be  well  borne  by  the  scalp  would 
probably  provoke  a  severe  inflammation  of  the  face. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Acidi  carbolici gr.  v-x 

Acidi  tannici  pulv £ss 

Glycerit.  tannini 3ss 

Sulphur,  praecip 5ss-5ij 

Ung.  aqua-  rosse 5j — M. 

S. — External  use.  Bulkley. 

1$ — Naphtholis 3j 

Saponis  viridis, 

Cretae  praep., 

Sulphuris  pntcip., 

Lanolini aa     3vj — M. 

S. — Apply  at  bedtime.  Morris. 


TINEA  IMBRICATA. 

Description. — This  fungus  disease  is  found  in  the  Malay 
Archipelago  and  certain  of  the  Pacific  islands.  The  dis- 
order may  attack  any  part  of  the  body,  but  usually  avoids 
the  scalp  and  other  hairy  parts.  It  is  contagious  and 
develops  about  nine  days  after  a  primary  inoculation. 
"The  disease  begins  with  inflamed  circular  patches, 
which  extend,  coalescing  with  neighboring  patches,  be- 
comes scaly  and  very  itchy,  and,  ultimately,  unless  its 
progress  is  arrested  by  treatment,  the  whole  surface  of 
the  body  becomes  affected.  The  scales  are  arranged  in 
concentric  circles,  in  spirals  or  in  irregular  curves  about 
one-quarter  of  an  inch  apart.  The  scales  stand  out  free, 
being  only  attached  by  one  edge  to  the  skin." 


TINEA   VERSICOLOR  481 

Treatment. — The  treatment  is  essentially  that  of  ring- 
worm. Thos.  W.  Jackson1  says  that  a  strong  solution  of 
salicylic  acid  in  alcohol  is  effective,  but  painful.  He  also 
recommends  citrine  ointment. 


TINEA  VERSICOLOR. 

Description. — Tinea  versicolor,  or  pityriasis  versicolor, 
is  a  vegetable  parasitic  disease  due  to  the  microsporon 
furfur.  It  attacks  adults  and  appears  on  the  trunk  in  the 
form  of  large  and  small,  slightly  scaly  patches  of  a  fawn 
color.  It  is  a  very  common  affection,  probably  occurring 
much  more  frequently  than  the  statistics  would  indicate. 

It  is  rarely  met  with  on  the  face  or  scalp2  and  never 
occurs  on  the  hands  or  feet,  being  limited  to  the  front  and 
back  of  the  chest,  the  covered  part  of  the  neck,  the  arms, 
the  axillae,  and  groins. 

It  begins  as  small,  round  spots  or  points  that  gradually 
enlarge,  and  finally,  by  coalescence  and  the  continuous 
development  of  new  lesions,  large  sheets  of  eruption  may 
be  formed.  The  spots  may,  however,  remain  discrete,  and 
even  where  large  patches  have  appeared,  smaller  spots  are 
to  be  seen  beyond  and  between  them,  as  well  as  on  other 
portions  of  the  trunk.  The  patches  are  but  slightly  ele- 
vated, and  are  usually  the  seat  of  a  finedesquamation,  or, 
if  the  scaling  is  not  well  developed,  it  can  be  made  more 
apparent  by  scraping  the  surface  with  the  finger-nail  or  a 
dull  knife.  The  color  has  been  well  described  as  fawn  or 
light  brown,  although  under  certain  circumstances  the 
patches  may  be  dark  brown,  or,  rarely,  almost  black.  Itch- 
ing is  not  a  marked  feature.  The  disease  when  allowed 
to  go  untreated  may  continue  indefinitely.  Although  a 
vegetable  parasitic  disease,  it  is  but  feebly  contagious. 

1  Tropical  Medicine,  P.  Blakiston's  Son  and  Co.,  Philadelphia,  l!)07. 

2  Biart  reports  a  case  of  tinea  versicolor  of  the  face,  and  Payne 
records  the  disease  on  the  scalp. 

31 


482  PARASITIC  DISEASES 

Tinea  versicolor  is  due  to  the  Microsporon  furfur,  which 
invades  the  superficial  layers  of  the  epidermis  only. 

Examined  under  the  microscope,  after  moistening  the 
scales  with  liquor  potassse,  this  parasite  is  seen  to  consist 
of  round  spores  of  a  uniform  size,  which  are  arranged  in 
masses  like  bunches  of  grapes.  The  spores  are  joined  by 
interlacing  mycelia.  The  arrangement  of  the  spores  in 
groups  is  quite  distinctive. 

Etiology. — Tinea  versicolor  is  a  disease  of  adult  life, 
although  occasionally  observed  in  children.  We  once  saw 
the  disease  in  a  child  of  eleven  years  who  wore  a  plaster 
jacket.  The  father  of  this  child  also  was  affected.  The 
idea  that  the  disorder  is  more  frequent  in  consumptives  is 
probably  due  to  the  fact  that  it  is  more  commonly  ob- 
served in  them  from  the  necessity  of  uncovering  the  chest 
for  physical  examination,  and,  perhaps,  also  to  their  great 
tendency  to  sweating,  a  condition  favorable  to  the  devel- 
opment of  the  fungus.  It  may  not  be  amiss  to  state  that 
tinea  versicolor  has  nothing  in  common  with  syphilis  or 
derangement  of  the  liver. 

Diagnosis. — The  recognition  of  the  disease  is  without 
difficulty  if  the  clinical  symptoms  are  remembered,  and 
in  case  of  doubt  the  microscope  will  readily  settle  the 
question. 

Chloasma,  the  affection  that  it  most  resembles  super- 
ficially, does  not,  however,  occur  on  the  trunk,  but  on 
the  face.  Seborrhea  of  the  trunk,  pityriasis  rosea,  the 
erythematous  syphiloderm,  and  erythrasma  should  be 
excluded  in  making  the  diagnosis. 

Prognosis. — The  temporary  removal  of  the  eruption  is 
more  or  less  readily  accomplished,  but  relapse  of  the  dis- 
ease is  to  be  expected  in  the  course  of  time. 

Treatment. — The  treatment  consists  in  washing  the 
parts  night  and  morning  with  green  soap  and  warm  water, 
and  afterward  the  free  application  of  the  following  lotion : 

1$ — Sodii  hyposulphitis ovj 

Aquae  destillatae 3iv — M. 

S. — Local  use. 


ERYTHRASMA  483 

In  many  cases  washing  the  surface  night  and  morning 
with  a  superfatted  soap  of  sulphur,  camphor,  and  balsam 
of  Peru  soon  causes  the  trouble  to  disappear. 

In  obstinate  cases  several  baths  a  week  of  the  hyposul- 
phite of  sodium — \  pound  to  30  gallons  of  water — helps  on 
the  cure.  An  ointment  of  sulphur  and  salicylic  acid — 1 
scruple  of  the  first  and  1  to  2  drachms  of  the  latter — is 
equally  efficacious.  Disinfecting  the  underclothing,  as 
suggested  by  Taylor,  undoubtedly  prevents  reinfection. 

ERYTHRASMA. 

Description. — This  slight  affection,  first  described  a 
number  of  years  ago  by  Burchardt,  and  later  by  Baren- 
sprung,  has  been  made  the  subject  of  further  study  in 
recent  years  by  Balzer,  Riehl,  Behrend,  and  others.  It 
occurs  in  situations  where  the  skin  is  in  contact,  e.  g., 
folds  of  axillee,  cleft  of  nates,  and  in  the  inguinal  and 
genitocrural  regions — and  consists  of  variously  sized, 
slightly  furfuraceous  patches  of  a  light-red  color,  which 
later  become  yellowish,  reddish,  or  brownish.  Occasion- 
ally the  patches  may  cover  large  surfaces  (Besnier).  It 
is  chronic  in  its  course,  and  gives  rise  to  no  especial  sub- 
jective sensations.  It  is  generally  agreed  that  the  disease 
is  due  to  a  parasite  first  called  by  Barensprung  the 
Microsporon  minutissimum. 

Prognosis. — The  disease  is  altogether  a  trivial  one  and 
readily  removed  by  treatment,  although  there  is  a  liability 
to  relapses. 

Treatment. — The  treatment  is  the  same  as  for  tinea 
versicolor.  The  following  ointment  rubbed  in  twice  a  day 
generally  suffices : 

I^ — Acidi  salicylic! 3j 

Sulphuris  pnrcipitati 5j 

Ung.  aquae  rosa1 3j — M. 

S. — For  local  use 

Hiehl  recommends  a  •',  per  cent,  alcoholic  solution  of 
corrosive  sublimate,  and  Wilkinson's  ointment. 


484  PARASITIC  DISEASES 


PINT  A  DISEASE. 

Description. — This  is  a  fungus  disease,  prevalent  in 
tropical  America,  which  produces  discolorations  of  the 
skin.  It  is  characterized  by  patches  of  various  shapes 
and  colors,  and  affects  the  exposed  parts  of  the  body 
except  the  palms  and  soles,  but  it  may  invade  the  entire 
surface,  including  the  scalp.  The  color  of  the  lesions 
varies  from  a  dull  white  to  grayish  blue,  or  red.  The 
patches  are  covered  with  a  branny  desquamation  in  the 
beginning,  but  later  the  scales  are  much  larger.  The 
hairs  turn  white  and  fall  out.  Ulceration  is  present  in 
severe  forms.  Itching  is  intense  and  the  emanations  from 
the  patients  very  offensive.  The  disease  is  very  chronic, 
but  spreads  slowly.  It  occurs  at  all  ages,  and  attacks,  by 
preference,  persons  in  the  lower  walks  of  life.  It  is  gen- 
erally supposed  to  be  contagious. 

Treatment. — The  treatment  is  by  the  application  of  anti- 
parasitic  remedies. 

MYCETOMA. 

Description. — Mycetoma,  Madura  foot,  or  podelcoma,  is 
a  disease  found  principally  in  India,  though  cases  have 
been  reported  in  this  country.1  There  are  three  varieties  of 
the  malady,  which  are  known  as  the  black,  the  white,  and 
the  red.  The  disease  attacks  generally  the  foot,  though  the 
hand  and  scrotum  may  be  affected.  The  first  evidence  of 
the  affection  is  a  vesicle,  pustule,  papule,  hard  nodule,  or  a 
black  mottling  of  the  skin  like  tattoo-marks.  After  a  time 
a  sinus  forms  which  discharges  pus,  whitish  bodies,  and 
then  black  masses  resembling  fish  roe.  In  a  fully  developed 
case  the  foot  is  much  distorted,  the  arch  broken  down,  and 
the  whole  foot  studded  with  nodules  representing  the  orifices 
of  sinuses.  About  the  sinuses  are  scattered  black  granules 

1  Hyde,  Journal  of  Cutaneous  and  Genito-urinary  Diseases,  Jan- 
uary 1890. 


ACTINOMYCOSIS  485 

in  the  skin.  The  discharge  of  the  roe-like  masses  from 
the  sinuses  is  the  most  characteristic  sign  of- the  disease. 
These  masses  contain  a  ray  fungus  very  similar  to  the 
actinomycosis  fungus,  although  not  identical  and  staining 
differently. 

Madura  foot  runs  a  very  chronic  course,  but  is  not 
usually  dangerous  to  life. 

Treatment. — Complete  removal  of  the  diseased  tissue 
seems  to  be  the  only  successful  treatment.  When  the 
disease  is  superficial,  scraping  with  the  sharp  spoon  may 
accomplish  this.  If  only  a  toe  or  a  finger  is  involved,  it 
should  be  amputated.  If  the  disease  is  advanced,  only  the 
removal  of  the  limb  well  above  the  affected  area  will 
suffice. 

ACTINOMYCOSIS. 

Description. — Actinomycosis  of  the  skin  is  a  very  rare 
affection.  It  usually  develops  as  secondary  to  a  deposit 
of  actinomyces  in  the  deeper  tissues.  The  disease  is 
most  common  in  the  neck  and  about  the  lower  jaw. 
Over  an  indolent,  hard  swelling  the  skin  becomes  thinned, 
red,  and  eventually  gives  way,  discharging  pus  which  may 
contain  the  characteristic  yellow,  pin-head-sized  granules. 
In  this  form  the  disease  very  much  resembles  what  is  seen 
in  tuberculous  glands.  When  a  sinus  has  thus  formed 
there  may  appear  about  the  opening  nodules  of  a  reddish 
or  bluish  hue,  which  may  suppurate. 

Actinomycosis  generally  arises  by  the  fungus  gaining 
access  to  the  body  through  a  carious  tooth,  and  this  ex- 
plains why  it  is  so  commonly  seen  about  the  neck  and 
jaw.  It  has  been  observed  to  attack  other  parts  of  the 
body. 

The  cause  of  the  disease  is  the  ray  fungus,  which  is  easily 
discovered  by  the  microscope  in  the  granules  mentioned 
above. 

Actinomycosis  is  usually  acquired  from  animals,  but  it 
is  possible  that  it  may  be  got  by  handling  straw  or  grain. 


486  ANIMAL  PARASITIC  AFFECTIONS 

The  disease  may  have  an  incubation  period  of  months  or 
years. 

The  only  way  to  make  a  positive  diagnosis  of  actinomy- 
cosis  is  to  find  the  fungus. 

Treatment. — It  was  formerly  thought  that  the  prognosis 
in  actinomycosis  was  invariably  bad.  On  this  account  the 
most  serious  operations  were  readily  undertaken.  More 
recent  observations  have  shown  that  a  large  propor- 
tion of  the  cases  live  many  years,  and  some  recover  spon- 
taneously, so  that  severe  operations  are  looked  upon  with 
disfavor.  When  possible,  sinuses  and  abscesses  should  be 
thoroughly  laid  open,  and,  after  curetting,  washed  with  a 
solution  of  bichloride  of  mercury.  Gautier  cured  a  case 
by  liberating  nascent  iodine  in  the  tissues  by  injecting 
solutions  of  iodide  of  potassium,  and  then  passing  a  gal- 
vanic current  by  needles  introduced  into  the  tissues. 

The  iodide  of  potassium  in  tolerably  large  doses  inter- 
nally should  always  be  faithfully  tried.  Rydygier  and 
others  have  reported  favorably  on  parenchymatous  local 
injections.  Bevan  gives  copper  sulphate  in  ^-gr.  doses, 
three  times  a  day.  Stelwagon  has  found  the  x-rays  of 
value. 

Pusey  believes  there  is  every  reason  to  use  the  rays  in 
conjunction  with  potassium  iodide.  So  far,  however, 
results  have  on  the  whole  been  unconvincing. 

Phototherapy  has  occasionally  been  of  use  in  the  late 
stage. 


ANIMAL    PARASITIC    AFFECTIONS. 
SCABIES. 

Description. — Scabies,  or  the  itch,  is  a  contagious  dis- 
ease of  the  skin  induced  by  the  presence  of  an  animal 
parasite,  the  Acarus  scabiei.  The  affection  is  very  common 
among  the  poorer  classes  in  Europe.  In  recent  years 
scabies  has  greatly  increased  in  this  countrv. 


SCABIES  487 

The  lesions  seen  in  scabies  are  cuniculi,  or  burrows, 
papules,  vesicles,  pustules,  and  various  secondary  effects  of 
scratching,  such  as  crusts,  excoriations,  furuncles,  etc.  It 
will,  therefore,  be  noted  that  the  symptoms  arise  directly 
from  the  inroads  of  the  itch  mite  in  the  first  place,  and, 
secondly,  from  the  traumatisms  inflicted  on  the  skin  by 
the  patient  himself.  The  chief  subjective  symptom  is 
intolerable  itching,  which  is  noted  to  be  greatly  aggravated 
after  the  patient  retires  to  bed.  It  must  not  be  supposed, 
however,  that  all  cases  of  scabies  present  the  same  symp- 
toms, since  these  will  depend  to  a  great  extent  upon  the 
age,  habits,  and,  perhaps,  susceptibility  of  the  infected 
person. 

The  burrows  are  by  no  means  always  to  be  detected,  and 
in  many  cases  cannot  be  made  out  at  all.  They  are  best 
seen  on  the  penis,  navel,  sides  of  the  fingers,  and  wrists, 
and  also  on  the  feet  of  children.  A  dark  spot  may  be  noted 
at  the  entrance  to  the  burrow,  the  acarus  lying  at  the 
other  end,  sometimes  enclosed  in  a  minute  vesicle.  The 
localization  of  scabies  is  characteristic.  In  a  general  way 
it  may  be  said  that  the  itch  insect  seeks  those  parts  of  the 
body  that  offer  the  most  warmth  and  moisture.  In  the  adult 
male  the  acarus  attacks  the  skin  between  the  fingers  and 
over  the  flexor  surfaces  of  the  wrists,  the  buttocks,  the 
lower  part  of  the  abdomen,  and  the  region  about  the 
internal  malleoli,  and  especially  the  penis.  In  women  the 
breasts  are  involved.  The  face  and  scalp  are  never  attacked 
in  grown  persons,  but  the  faces  of  infants  at  the  breast 
may  be  invaded.  Children  are  also  apt  to  show  the  disease 
on  the  feet  and  buttocks,  particularly. 

The  inflammatory  lesions  of  scabies  are  often  multiform, 
that  is  to  say,  papular,  vesicular,  pustular,  and  in  prolonged 
or  severe  cases  various  secondary  changes  may  be  present 
at  one  and  the  same  time.  On  the  contrary,  however,  the 
disorder  may  be  so  mild  that  a  few  papules  and  vesicles 
only  are  present.  The  lesions  are  irregularly  scattered, 
and  do  not  form  groups. 

The  disease  is  a  dermatitis  or  artificial  eczema  due 


488  ANIMAL  PARASITIC  AFFECTIONS 

directly  to  contagion,  that  is,  the  conveyance  of  an  im- 
pregnated female  acarus  to  the  skin. 

Notwithstanding  that  under  favorable  conditions  scabies 
is  highly  contagious,  it  is  a  noteworthy  fact  that  the  affec- 
tion is  not  conveyed  in  the  ordinary  intercourse  of  life, 
such  as  hand  shaking;  nor  do  physicians  seem  to  acquire  it 
in  the  manipulation  of  affected  persons.  Sleeping  in  the 
same  bed,  wearing  infected  clothing,  and  the  like,  are  the 
principal  agents  of  propagation.  The  acarus  respects 
neither  age,  sex,  nor  social  condition. 

Diagnosis. — The  diagnosis  of  scabies  is,  as  a  rule,  readily 
made.  Absolute  certainty  can  only  come  from  the  dis- 
covery of  the  acarus  or  of  its  burrow;  but  as  it  is  often 
impossible  to  demonstrate  their  presence,  we  are  generally 
obliged  to  rely  on  the  rational  signs  of  the  disease.  The 
localization  of  the  dermatitis  is  nearly  always  characteristic, 
viz.,  the  skin  between  the  fingers,  the  flexor  sides  of  the 
wrists,  the  lower  part  of  the  abdomen,  the  buttocks,  the 
penis  in  the  male,  and  the  breasts  in  the  female.  The 
absence  of  such  a  generalized  eruption  from  the  face  in  the 
adult  is  always  a  noteworthy  circumstance,  and  its  tolerably 
definite  restriction  to  the  parts  mentioned  adds  greatly 
to  the  suspicion.  In  children  this  localization  is  much  less 
strict;  the  face  and  the  feet  may  both  be  affected,  while, 
on  the  contrary,  the  disorder  may  be  absent  from  the 
hands,  and  more  developed  on  the  trunk  and  the  nates. 
In  children  large  pustules  and  even  bullse  may  be  encoun- 
tered. While  the  lesions  of  an  eczema  are  spoken  of  as 
being  multiform,  they  are  not  so  in  the  manner  seen  in 
scabies;  that  is  to  say,  they  are  not  seen  as  a  discrete, 
widely  spread  eruption  of  papules,  vesicles,  pustules,  etc. 
Pediculosis  corporis  is  found  on  the  covered  portions  of  the 
body,  especially  on  the  upper  part  of  the  trunk,  and  the 
lesions  are  altogether  dissimilar.  Finally,  the  evidence  of 
contagion  taken  in  connection  with  the  other  symptoms  is 
a  most  important  aid  in  diagnosis. 

Prognosis. — Scabies  is  a  perfectly  curable  disease,  pro- 
vided the  treatment  be  thoroughly  carried  out,  and  the 
proper  precautions  taken  against  the  risk  of  reinfection. 


SCABIES  489 

Treatment. — The  disease  is  quickly  amenable  to  properly 
directed  treatment.  Sulphur  in  some  form  is  the  most 
satisfactory  remedy.  The  usual  plan  is  to  direct  the  patient 
to  take  a  hot  bath  with  frictions  of  green  soap,  and  after- 
wards to  apply  the  following  ointment  morning  and  evening 
for  three  days: 

1$ — Sulphuris  prsecipitati 3xij 

Vaselini 5vj 

Olei  rosse q.  s. — M. 

S. — Rub  in  1  oz.  thoroughly  ni  ht  and  morning. 

The  salve  must  be  well  worked  into  the  skin,  especially 
in  those  parts  most  covered  with  the  eruption.  It  is  not 
necessary  to  apply  it  to  the  face.  We  usually  direct  that 
the  patient  keep  on  the  same  underclothes,  and  sleep  in  the 
same  sheets,  during  the  course.  If  the  treatment  has  been 
completed  in  the  morning  the  same  garments  are  kept  on 
until  night,  when  a  hot,  soap  bath  is  again  taken,  and  fresh 
underclothes  put  on  and  the  sheets  renewed.  For  perhaps 
a  week  longer  a  small  amount  of  salve  may  be  rubbed  in  at 
night,  in  order  to  make  assurance  doubly  sure.  It  is  a 
sine  qua  non  of  the  treatment  that  the  underclothing  and 
sheets  be  disinfected  by  boiling.  The  outer  garments 
should  be  thoroughly  ironed  with  a  hot  iron. 

Sherwell  advises  the  use  of  sulphur  in  powder  form. 
After  a  bath  with  soap  he  directs  that  one-half  teaspoonful 
of  the  flowers  of  sulphur  be  gently  rubbed  in  over  the 
body,  and  that  the  same  amount  be  sprinkled  between  the 
sheets  at  bed  time.  This  process  may  be  repeated  every 
two  or  three  days,  the  cure  taking  about  one  week. 

A  large  number  of  other  parasiticides  have  been  recom- 
mended. McCall  Anderson  speaks  highly  of  styrax: 

1$ — Styracis  liquid! 3j 

Adipis 5ij — M. 

Duhring  recommends  balsam  of  Peru  in  conjunction 
with  sulphur  for  scabies  in  children : 

1^ — Sulphuris  sublimati 5j 

Balsami  Poruviani 5ss 

Adipis 5j — M. 


490  ANIMAL  PARASITIC  AFFECTIONS 

Jullien  and  Descouleurs1  say  that  in  the  treatment  of 
scabies  it  is  sufficient  to  paint  a  thin  coat  of  balsam  of  Peru 
over  the  skin  and  to  rub  it  in  gently,  a  previous  soaping 
not  being  necessary.  The  application  is  made  at  night, 
and  the  next  day  a  bath  is  taken.  The  authors  claim  for 
this  method  certainty  and  simplicity,  and  assert  that  it  is 
especially  indicated  when,  for  any  cause,  baths  are  not 
indicated.  It  should  be  remembered  that  balsam  of  Peru 
sometimes  causes  toxic  symptoms. 

Hebra's  modification  of  Wilkinson's  ointment  is  much 
used  abroad: 

1$ — Sulphuris  sublimati, 

Olei  cadini .   aa  oiv 

Cretse  prscparatse Sijss 

Saponis  viridis, 

Adipis aa  3j — M. 

An  ointment  of  naphthol,  chalk,  and  green  soap,  as  sug- 
gested by  Kaposi,  is  very  effectual  and  elegant: 

1$ — Naphtholis 3ss 

Saponis  viridis 5jss 

Cretse  alb.  pulv Sjjss 

Adipis 5iij — M. 

If  after  a  course  of  specific  treatment  the  skin  is  left 
inflamed  and  irritable,  it  will  be  necessary  to  prescribe 
soothing  remedies,  although,  as  a  general  thing,  the  cause 
of  the  dermatitis  having  been  removed,  recovery  is  speedy. 
It  should  be  added,  however,  that  in  a  certain  considerable 
proportion  of  persons,  especially  the  neurotic,  the  pruritus 
remains  for  weeks  and  is  more  difficult  to  combat  than  the 
original  disorder.  Sometimes  this  secondary  affection,  with 
its  accompanying  eruption,  is  strongly  suggestive  of  der- 
matitis herpetiformis.  The  treatment  consists  in  the 
administration  of  nervines  internally  and  the  local  appli- 
cation of  lotions  containing  menthol  and  carbolic  acid. 
(See  Pruritus.) 

1  Annales  de  dermatologie  et  de  syphiligraphie,  April,  1S9G. 


PEDICULOSIS  491 

ADDITIONAL  PRESCRIPTIONS. 

1^ — Styracis  liq gj 

Spt.  rectificati 5ij 

Olei  olivje 3j — M. 

S. — External  use.    Enough  for  one  person.  Schultze. 

1} — Sulphuris  sublimati 5iv-  3vj 

Balsami  peruviani 3iv 

Beta-naphtholis 3j-3ij 

Adipis  benzoati, 

Petrolati aa  q.  s.  ad  5iv — M. 

Stel  wagon. 
1$ — Balsami  peruviani, 

Alcoholis aa     5j — M. 

S. — To  be  painted  on  with  a  brush.  Walker. 

1$ — Olei  verbena? .         1  part 

Gummi  tragacanthse 1  part 

Sulphuris  praecip 100  parts 

Glycerini 200  parts — M. 

S. — First  rub  patient  with  green  soap,  vhen  give  an  alkaline  bath; 
afterward  apply  the  ointment  about  the  whole  body,  and  then  again 
a  bath  for  twenty  minutes.  For  two  weeks  following,  four  baths  of 
starch-water  should  be  given  and  zinc  salve  applied  if  skin  is  irritable. 

Sabouraud. 

PEDICULOSIS. 

Description. — Pediculi,  or  lice,  infest  different  portions 
of  the  human  body,  and  give  rise  to  a  contagious  affection 
variously  called  pediculosis,  phtheiriasis,  or,  in  common 
parlance,  lousiness.  Three  varieties  of  lice  are  met  with, 
which  differ  both  in  their  form  and  habitat.  The  symp- 
toms that  they  occasion  really  constitute  a  dermatitis,  or 
artificial  eczema,  but  certain  differences  in  clinical  expres- 
sion will  be  noted,  according  to  the  region  invaded. 

Pediculosis  Capillitii.  Description. — This  is  the  most 
frequent  form  of  pediculosis,  and  is  due  to  the  presence  of 
the  Pediculus  capitis  or  head  louse.  The  pediculi  may  be 
present  in  large  or  small  numbers,  and  may  be  detected  upon 
the  hair  or  scalp,  but  generally,  however,  the  nits  are  more 
readily  discovered.  The  occipital  region,  as  affording  the 
two  conditions  of  heat  and  moisture,  is  the  favored  region 
for  the  head  louse.  Pediculosis  capillitii  is  more  frequent 


492  ANIMAL  PARASITIC  AFFECTIONS 

in  children  and  in  women  than  in  the  adult  male  and  it 
is  more  common  in  the  poorer  classes.  There  is  usually 
much  soreness  of  the  scalp,  and  the  irritation  set  up  by  the 
attacks  of  the  pediculi  causes  scratching  which  in  turn 
produces  the  lesions  so  characteristic  of  pediculosis  in  this 
situation,  namely,  abrasions  and  excoriations,  a  foul, 
sticky  secretion  that  mats  the  hair  together,  and  greenish, 
yellow  crusts.  The  ravages  of  the  pediculi  are  generally 
limited  to  the  scalp,  but  when  the  hair  is  long,  similar 
lesions  may  be  seen  on  the  contiguous  skin. 

A  sympathetic  enlargement  of  the  occipital  glands,  as 
well  as  of  those  in  front  of  the  ears  and  at  the  sides  of  the 
neck,  is  the  usual  accompaniment  of  pediculosis  capillitii, 
and  in  neglected  cases  suppuration  may  occur.  Even  the 
general  health  may  materially  suffer  from  long-continued 
nervous  erethism  and  loss  of  sleep  induced  by  the  incessant 
pruritus.  The  presence  of  a  pustular  eczema  in  the  occipi- 
tal region,  with  coincident  lymphatic-gland  enlargement, 
occurring  in  a  woman  or  child,  gives  rise  to  a  fair  presump- 
tion that  the  affection  is  due  to  lice. 

With  a  little  care  the  parasites  themselves  may  generally 
be  discovered,  and  an  examination  of  individual  hairs  will 
show  the  ova,  or  nits,  attached  to  them  near  the  roots, 
looking  like  minute,  grayish-white  scales.  One  nit  only  is, 
as  a  rule,  attached  to  a  hair,  but  sometimes  a  dozen  or  more 
may  be  counted.  A  nit  is  to  be  distinguished  from  a  scale 
by  the  fact  that  the  former  is  glued  to  the  hair  on  one  side 
and  cannot  be  readily  brushed  off,  while  a  scale  is  often 
pierced  by  the  hair  shaft  and  may  be  removed  without 
difficulty.  The  pediculi  escape  from  the  ova  in  from  three 
to  nine  days,  are  full  grown  in  about  nine  days  more,  and 
at  the  end  of  a  similar  period  are  capable  of  reproduction. 

Treatment. — The  disorder  is  readily  cured,  but  a  complete 
and  permanent  success  is  only  secured  by  destroying  the  nits 
as  well  as  the  pediculi.  The  most  effectual  plan  is  to  shave 
off  the  hair,  and  apply  soothing  preparations  for  the  relief 
of  the  dermatitis;  but  as  this  procedure  is  not  always 
desirable,  it  is  necessary  to  employ  other  measures.  If  it 


PEDICULOSIS  493 

is  determined  not  to  cut  the  hair,  the  physician  may  order 
equal  parts  of  petroleum  and  olive  oil,  or  the  petroleum 
alone,  to  be  rubbed  into  the  hair  with  white  flannel,  taking 
care  to  keep  it  from  running  down  on  the  neck  and  face, 
and  following  up  the  application  next  morning  with  a  hot 
shampoo  of  soap  and  water.  In  order  to  get  rid  of  the  nits, 
the  hair  may  be  washed  with  vinegar  to  dissolve  the  little 
rings  by  which  they  are  attached,  after  which  a  fine-tooth 
comb  may  be  employed  to  detach  them. 

This  latter  procedure  should  be  kept  up  for  a  week  or 
two.  Any  local  inflammatory  symptoms  that  are  left  over 
after  the  destruction  of  the  pediculi  should  be  treated  on 
general  principles. 

Pediculosis  Corporis .  Description. — The  body  or,  more 
accurately,  the  clothes  louse  attacks  mostly  elderly  people 
of  the  poorer  classes,  although  it  should  always  be  remem- 
bered that  persons  of  wealth  and  refinement  may  be  acci- 
dentally infected.  These  pediculi  confine  their  depredations 
to  the  body,  but  they  are  rarely  to  be  found  on  the  sufferer, 
since  they  live  in  the  seams  of  the  undergarments,  where 
their  ova  are  deposited,  the  skin  itself  being  used  as  a  feeding 
ground  only.  The  bite  of  the  insect  consists  of  a  minute 
hemorrhagic  dot,  surrounded  by  a  red  areola,  which  may 
be  effaced  by  pressure,  the  central  dark  speck  being,  how- 
ever, left  intact.  Most  of  the  lesions  present  are  caused 
by  the  efforts  of  the  patients  to  relieve  the  intolerable  itch- 
ing aroused  by  the  parasite,  and  are  made  up  of  excoriations 
from  the  nails,  and  of  a  variety  of  papular,  pustular,  urti- 
carial,  and  f  uruncular  eruptions.  In  long-standing  cases  the 
affected  regions  become  deeply  pigmented,  and  covered 
with  scales  and  crusts.  While  the  eruption  may  be  dis- 
covered on  various  parts  of  the  body,  it  is  mostly  to  be 
found  on  the  neck  and  shoulders. 

The  diagnosis  is  most  certainly  fully  established  by  find- 
ing the  parasite,  either  on  the  body,  which  is  rare,  or  in 
the  scams  and  folds  of  the  garments;  but  as  clean  clothes 
are  often  put  on  just  before  the  physician  is  consulted, 
it  is  necessary  to  bear  in  mind  the  character  of  the  lesions 


494  ANIMAL  PARASITIC  AFFECTIONS 

just  described,  and  especially  the  location  of  the  eruption 
about  the  neck  and  back. 

Treatment. — The  treatment  should  be  mainly  directed  to 
getting  rid  of  the  lice  in  the  clothing.  This  is  best  accom- 
plished by  long-continued  boiling,  or  by  baking  in  an  oven 
at  a  temperature  of  at  least  210°  F.  It  is  also  useful,  accord- 
ing to  Anderson,  to  sprinkle  some  of  the  powder  of  staphi- 
sagria  upon  them.  This  same  substance  in  ointment  may 
be  rubbed  upon  the  skin  to  kill  any  wandering  marauders 
that  may  be  found  there.  The  patient  should  be  freely 
scrubbed  with  soap  and  water,  and  afterward  the  irritable 
or  inflamed  skin  may  be  treated  as  if  for  eczema.  Bed- 
clothing  should  also  be  disinfected.  In  broken-down  sub- 
jects, tonics  and  cod-liver  oil  are  indicated.  Jamieson 
suggests  wearing  a  piece  of  roll  sulphur  in  a  bag. 

Pediculosis  Pubis.  Description. — The  pubic  louse  so 
called  does  not  invade  the  head,  but  is  mostly  found  in  the 
pubic  region,  as  well  as  sometimes  on  other  parts,  namely, 
the  axillae,  the  hairy  thorax,  and  even  the  eyebrows  and  eye- 
lashes. The  lice  may  be  seen  as  little  dark  specks  attached 
to  the  hair  near  the  skin.  They  attack  adults  usually,  and 
are  most  frequently  conveyed  in  sexual  intercourse,  but  by  no 
means  always.  The  irritation  caused  by  the  presence  of  the 
crab  louse  is  not  so  violent  as  with  the  other  varieties,  but 
the  itching  leads  to  scratching,  and  in  this  way  papular  and 
other  eczematous  lesions  are  produced.  Crab  lice  often 
produce  a  peculiar  steel-gray  pigmentation  (macula? 
caerulese)  upon  the  skin,  of  the  size  of  the  finger-nail  or 
somewhat  less,  and  situated  on  the  inside  of  the  thighs,  the 
pubes,  abdomen,  and  axillee.  The  color  is  thought  to  be 
derived  from  a  pigment  in  the  salivary  glands  of  the  insect. 
These  spots  do  not  fade  upon  pressure,  but  disappear  when 
the  pediculi  have  been  destroyed.  The  classical  treatment 
consists  in  the  free  inunction  of  the  blue  ointment,  but  a  10 
per  cent,  oleate  of  mercury  is  more  cleanly  and  much  less 
irritating.  Sublimate  alcohol,  1  to  1000,  is  still  better. 
Kaposi's  petroleum  salve — 5  parts  of  petroleum,  1\  parts 
of  olive  oil,  and  1  part  of  balsam  of  Peru — is  both  elegant 


FILARIA  MEDINENSIS  495 

and  efficacious.  After  the  remedies  have  been  applied 
several  times  a  bath  may  be  taken.  It  is  best  not  to  clip 
or  shave  the  hairs.  Mouse-tooth  forceps  are  convenient 
for  pulling  the  insects  off  the  eyelashes. 

ADDITIONAL  PRESCRIPTIONS. 

1$ — Hydrarg.  bichloridi gr.  ijss 

Acid,  acetici  arora 3j — M. 

S. — External  use.  Regensburger. 

Ifr — Pulv.  staphisagriae 5j 

Adipis giv 

Digest  together  for  three  hours,  strain  and  add 

Oleum  staphisagriaj 3  j 

Adipem 5j — M. 

S. — External  use.  Tilbury  Fox. 


FILARIA  MEDINENSIS. 

Description. — The  Guinea-worm  is  a  white  worm,  one- 
tenth  inch  in  diameter  and  two  to  three  feet  long.  It  is  met 
with  only  in  tropical  countries.  The  parasite  enters  the  body 
by  the  larvae  being  swallowed,  and  not,  as  was  formerly 
supposed,  by  the  creature  boring  its  way  into  the  tissues 
from  without.  The  mischief-maker  is  the  female  worm,  the 
male  never  having  been  discovered.  The  usual  site  of  the 
lesions  is  the  skin  about  the  ankles,  but  it  is  also  met  with 
on  the  legs  and  thighs,  scrotum,  conjunctive,  under  the 
tongue,  etc.  Usually,  one  worm  only  is  present,  but  some- 
times two,  or  even  many  more.  When  the  worm  has  devel- 
oped to  maturity,  it  tries  to  make  its  way  into  the  outer 
world,  and  at  a  circumscribed  spot,  where  for  some  time 
has  existed  an  uneasy  sensation,  the  skin  will  begin  to 
show  some  signs  of  irritation.  Presently  slight  fluctuation 
can  be  determined.  Sometimes  violent  reaction  results, 
causing  phlegmon  or  even  gangrene. 

Treatment. — AVhen  rupture  occurs,  the  head  of  the  worm 
will  protrude,  and  its  gradual  extraction  is  attempted  by 
winding  it  around  a  stick,  one  inch  or  more  daily,  taking 


496  ANIMAL  PARASITIC  AFFECTIONS 

especial  pains  not  to  break  the  body  of  the  parasite  during 
the  process.  This  method  is  tedious,  and  has  been  advised 
against  by  Manson,  who,  with  Emily,  recommends  inject- 
ing into  the  worm  as  it  lies  under  the  skin  a  1  to  1000  solution 
of  bichloride  of  mercury.  Christie  suggests  the  electrolytic 
destruction  of  the  worm.  Tincture  of  asafetida,  in  1-  or 
2-drachm  doses,  three  times  a  day,  has  been  recommended 
in  addition. 


CYSTICERCUS  CELLULOSJE  CUTIS. 

Description. — The  cysticercus  of  the  Tamia  solium  is 
occasionally  found  in  the  subcutaneous  tissue,  where  it 
forms  tumors  from  pea  to  marble  size,  round,  and 
covered  by  unaltered  skin.  In  the  early  stages  the  tumors 
are  tense  and  elastic,  but  in  time  may  undergo  calcareous 
change.  Usually  several  tumors  are  found,  more  com- 
monly on  the  back. 

Echinococcus  cysts  have  also  been  found  in  the  skin, 
where  they  form  fluctuating  tumors. 

CREEPING  ERUPTION. 

Description. — This  curious  malady,  due  to  the  invasion 
of  the  skin  by  a  minute  larva,  is  not  uncommon  in  southern 
Russia  and  adjacent  countries.1  The  lesions  consist  of  a 
red  line  from  one-sixth  to  one-eighth  of  an  inch  in  width  and 
just  perceptibly  elevated.  This  line  extends  itself  at  the 
rate  of  one  inch  or  more  a  day  and  may  traverse  a  con- 
siderable portion  of  the  surface  of  the  body.  Its  march  is 
sometimes  in  a  straight  line,  although  usually  curves  and 
bends  are  to  be  noted. 

Treatment. — The  treatment  is  by  excision  or  cauteri- 
zation. Stelwagon  applied  by  cataphoresis  a  solution  of 

1  Cases  have  been  observed  in  this  country  by  Van  Harlingcn, 
Stelwagon,  and  Shelmire. 


CREEPING  ERUPTION  497 

2  gr.  of  mercuric  chloride  to  1  oz.,  to  an  area  of  one  and 
one-half  inches  around  the  advancing  end  of  the  burrow, 
and  applied  a  small  drop  of  nitric  acid  to  the  suspected 
site  of  the  parasite,  just  beyond  the  extreme  end  of  the 
line. 

He  believes  that  the  high-frequency  current  would  be 
successful.  Cathcart  freezes  this  advancing  end  of  the 
line  or  burrow  with  ethyl  chloride,  and  finds  that  a  single, 
thorough  application  suffices  to  kill  the  parasite. 

Electrolysis  would,  perhaps,  prove  useful. 

Hutchins  suggests  the  injection,  after  cocainizing,  of  1 
or  2  drops  of  chloroform,  pushing  the  needle  along  the 
burrow  to  the  probable  site  of  the  grub. 

Quite  a  large  number  of  insects,  such  as  the  flea,  the 
mosquito,  the  tick,  bedbug,  wasp,  bee,  etc.,  attack  the 
human  skin  and  set  up  more  or  less  dermatitis  accompa- 
nied by  burning,  stinging,  and  itching. 

The  treatment  of  the  inflammation  which  results  from 
the  bites  and  stings  of  insects  consists,  in  the  first  place,  in 
the  removal  of  the  cause,  and,  secondly,  in  allaying  the 
burning  and  itching.  For  this  latter  purpose  cooling  and 
antipruritic  lotions  are  serviceable,  such  as  cologne,  vinegar, 
weak  carbolic  acid  lotions,  and  especially  menthol  in 
combination  with  the  calamine  and  zinc  lotion : 

1$ — Mentholis 3j-3ij 

Alcoholis 

Zinci  oxidi 

Pulv.  calaminae 

Glycerin! 3|j 

Liq.  calcis q.  s.  ad     5iv — M. 

A  pigment  of  salicylic  acid  1  part  and  flexible  collodion 
19  parts  is  a  valuable  application  for  the  stings  of  various 
insects.  Pick's  linimentum  exsiccans  with  10  per  cent, 
zinc  oxide  and  1  per  cent,  carbolic  acid  is  also  an  excellent 
application. 


32 


498  ANIMAL  PARASITIC  AFFECTIONS 


MYIASIS. 

Description. — The  larvae  of  the  oestrus  (bot-fly,  gad-fly) 
and  of  other  cestrida  are  sometimes  found  in  the  sub- 
cutaneous cellular  tissue  of  man,  the  ova  having  been 
deposited  through  a  puncture  in  the  skin  made  by  the 
adult  female.  A  boil-like  lesion  develops  at  the  site  occu- 
pied by  the  grub,  and  soon  forms  a  central  aperture  through 
which  there  discharges  a  serous  fluid,  admixed  with  blood 
and  pus.  The  worm  may  burrow  for  a  considerable  dis- 
tance under  the  skin  before  exciting  much  suppuration,  in 
which  case  there  results  a  sinuous,  purplish-red  line,  clini- 
cally much  like  those  seen  in  lymphangitis.  This  consti- 
tutes the  "creeping  eruption,"  described  separately.  The 
condition,  rare  here,  is  relatively  common  in  some  countries 
lying  to  the  south  of  us,  and  in  Russia. 

Treatment. — The  treatment  of  the  furuncular  lesions 
consists  in  laying  them  open,  whereupon,  the  larva  may  be 
extruded  by  lateral  pressure. 

The  muscidse  (dung-fly,  flesh-fly,  etc.)  do  not  penetrate 
the  skin.  The  larvae  may,  however,  be  deposited  in  wounds 
or  ulcers  or  between  the  folds  of  skin,  presenting  a  par- 
ticularly nauseous  spectacle.  The  necessary  treatment  is 
sufficiently  obvious. 


UNCINARIAL  DERMATITIS. 

Description. — The  Porto  Rico  Anemia  Commission  has 
shown  that  the  hook-worm,  in  the  great  majority  of 
cases,  invades  the  organism  by  way  of  the  skin.  96  per 
cent,  of  their  patients  had  had  "mazamorra"  or  ground- 
itch,  "a  lesion  abundantly  shown  to  be  due  to  the  invasion 
of  the  healthy  skin  by  these  larvae,"  as  claimed  by  Loos, 
Claude  Smith,  and  others. 


UNCINARIAL  DERMATITIS  499 

Drs.  Ashford  and  King,  of  the  United  States  army, 
describe  the  condition  as  follows  i1 

"Contact  of  the  skin  with  mud  laden  with  encysted  larvae 
for  a  time  not  necessarily  longer  than  from  a  few  minutes 
to  one-half  hour  causes  first  itching,  then  redness  and 
swelling  of  the  part,  with  the  formation  in  a  couple  of  days 
of  papules,  rapidly  becoming  vesicles.  In  favorable  cases 
pustulation  does  not  occur,  but  when  the  invasion  of  many 
larvae  has  profoundly  inflamed  the  part,  and  the  ordinary 
organisms  of  pus  have  obtained  a  foothold,  not  only  do 
pustules  form,  but  extensive  ulceration  may  result,  which 
is  extremely  resistant  to  treatment." 

Treatment. — Prophylaxis  may  be  summed  up  in  the 
statement  "that  the  well-shod  are  practically  never  in- 
fected." Treatment  should  be  directed  against  the  pruri- 
tus and  secondary  pus  infection.  It  is  said  that  turpentine 
is  very  efficacious  if  applied  early.  Ointments  of  thymol 
or  beta-naphthol  naturally  suggest  themselves  in  view  of 
the  efficaciousness  of  these  remedies  in  killing  the  larvae  in 
the  alimentary  canal. 

1  Journal  of  American  Medical  Association,  August  10,  1907,  p. 
471. 


PART  II. 
GENERAL  TREATMENT  AND  METHODS. 


INTERNAL  TREATMENT. 

THE  internal  treatment  of  skin  diseases  is  mainly  symp- 
tomatic, and,  according  to  the  indications  present,  there 
may  be  prescribed,  just  as  for  any  other  bodily  disorder, 
iron,  quinine,  cod-liver  oil,  purgatives,  stomachics,  or 
diuretics.  We  may  also  mention  the  benefit  of  lavage  of 
the  stomach  in  rosacea,  urticaria,  and  recurrent  eczema  of 
the  face. 

A  large  number  of  the  diseases  of  the  skin  require  local 
treatment  only,  a  minority  constitutional  treatment  only; 
perhaps  the  majority  demand  a  judicious  combination  of 
the  two.  Moreover,  in  the  rational  management  of  cutane- 
ous affections,  it  is  essential  that  the  physician  regulate 
the  dietary  of  his  patient  intelligently,  and  that  he  give 
him,  besides,  proper  instruction  in  the  details  of  personal 
hygiene.  As  these  matters  have  received  the  proper 
amount  of  attention  in  the  special  sections  of  this  book,  it 
will  not  be  necessary  to  repeat  them  here.  It  remains, 
therefore,  to  call  attention,  briefly,  to  certain  internal 
remedies  that  are  supposed  to  have  a  direct  or  specific 
effect  upon  diseases  of  the  skin. 

Arsenic. — There  is  no  other  article  in  the  materia  medica 
more  widely,  and  at  the  same  time,  more  ignorantly  and 
harmfully  used.  As  a  rule,  it  is  contra-indicated  in  all 
acute  eruptions,  and  its  chief  value  is  in  chronic,  scaly 


502          GENERAL  TREATMENT  AND  METHODS 

affections,  psoriasis,  lichen  planus,  and  in  disorders  that 
are  regarded  as  neurotic,  e.  g.,  pemphigus,  dermatitis 
herpetifonnis.  It  is  also  said  to  be  of  advantage  in  sarcoma 
and  epithelioma.  The  prolonged  administration  of  arsenic 
is  not  devoid  of  danger,  since  it  may  induce  neuritis,  and, 
locally,  may  cause  certain  epithelial  changes  such  as 
warty  growths  and  probably  the  eventual  production  of 
epithelioma.  Pigmentation  following  its  use  is  not  uncom- 
mon. Arsenic  may  be  given  in  pill  or  solution,  or  hypoder- 
mically  in  the  form  of  sodium  arsenate.  It  has  not  been 
established  that  the  various  other  preparations  of  arsenic 
such  as  the  cacodylates,  etc.,  have  any  superiority  over  the 
older  preparations. 

Antimony. — This  drug,  in  the  form  of  the  wine,  has  been 
somewhat  employed  of  late  years  in  the  treatment  of  acute 
and  subacute  inflammatory  diseases  of  the  skin,  such  as 
eczema,  psoriasis,  and  lichen  planus.  Duhring  states  that 
in  small  doses  it  is  sometimes  of  benefit  in  chronic  disorders. 

The  usual  dose  is  from  3  to  10  minims  several  times  a  day. 
As  it  is  a  decided  depressant  its  action  should  be  carefully 
watched. 

Sulphur. — Sulphur  once  shared  with  arsenic  the  repu- 
tation of  a  panacea  for  all  kinds  of  skin  diseases,  and, 
although  it  is  still  regarded  as  invaluable  as  a  local  remedy, 
its  internal  use  has  for  many  years  been  much  neglected. 
Nevertheless,  within  certain  limits,  sulphur  given  internally 
is  not  without  considerable  value.  Crocker  regards  it 
most  favorably  in  hyperidrosis.  Walker  says  that  it  is 
occasionally  useful  in  erythema  multiforme,  and  we  believe 
that  it  has  a  decided  value  in  acne,  dystrophies  of  the  nails, 
and  in  seborrhea.  The  sulphide  of  calcium  is  given  in 
pustular  acne  and  f urunculosis,  and  Duhring  recommends 
the  hyposulphite  of  sodium  in  urticaria  and  furuncu- 
losis. 

Ichthyol. — Ichthyol  contains  nearly  15  per  cent,  of  sul- 
phur, but  has  certain  therapeutic  properties  that  are  not 
due  to  that  ingredient.  Internally,  it  is  given  in  urti- 
caria and  hyperemic  affections  of  the  face. 


INTERNAL  TREATMENT  503 

Quinine. — In  urticaria  of  malarial  character  quinine 
may  be  given  with  advantage.  In  large  doses  it  has  a 
decided  influence  upon  pruritus,  and  it  is  at  times  useful 
in  the  acute  erythemata  and  in  lichen  planus.  According 
to  Duhring  it  is  valuable  in  elephantiasis,  and  by  some 
authorities  it  is  regarded  as  almost  specific  in  erysipelas. 

Salicylic  Acid. — Salicin  and  the  salicylates  are  of  extreme 
value  in  the  erythemata,  and,  according  to  Walker,  salicylic 
acid  is  virtually  a  specific  in  erythema  nodosum.  Sali- 
cylate  of  sodium  is  useful  in  general  pruritus.  Salicin  is 
preferable  to  the  various  other  combinations  of  salicylic 
acid,  as  it  is  less  irritating  and  depressing.  Crocker  recom- 
mends salicin  highly  in  lupus  erythematosus,  psoriasis, 
lichen  planus,  and  in  bullous  affections.  We  concur  in  the 
main  with  his  estimate  of  the  drug.  The  dose  advised  is 
15  gr.  three  times  a  day,  and  this  may  be  increased  to  20 
or  25  gr. 

Phosphorus. — Phosphorus  is  advised  by  Bulkley  in  the 
treatment  of  lupus  erythematosus,  and  phosphide  of  zinc 
by  Ashburton  Thompson  as  serviceable  in  herpes  zoster. 

Turpentine. — This  drug  is  recommended  by  Crocker  in 
uncomplicated  cases  of  eczema  and  inflammatory  cases  of 
psoriasis. 

Tar  and  Carbolic  Acid. — Both  of  these  drugs  have  been 
given  in  psoriasis  and  chronic  eczema  with  asserted  advan- 
tage. It  has  also  been  advised  internally  for  pruritus. 

Calcium  Chloride. — On  theoretical  grounds  this  drug  has 
been  recommended  by  Wright  in  urticaria.  Savill  pre- 
scribes it  in  various  forms  of  pruritus,  and  it  is  also  advised 
in  chilblain  and  ulcers  of  the  legs.  The  dose  is  from  5 
to  20  gr.  three  times  a  day.  It  should  be  given  after  meals 
well  diluted. 

Thyroid  Gland. — Thyroid  extract  is  extremely  efficacious 
in  myxedema,  and  has  been  given  with  a  certain  degree  of 
success  in  psoriasis  and  ichthyosis,  and  as  an  adjuvant  in 
the  treatment  of  lupus  and  cancer.  Small  doses  should  be 
given  at  first  and  the  amount  increased  only  gradually. 
It  is  much  better  borne  if  combined  with  arsenic. 


504         GENERAL  TREATMENT  AND  METHODS 

Suprarenal  Extract. — Suprarenal  gland  has  been  found 
of  some  value  in  Addison's  disease,  and  it  has  been  sug- 
gested in  leucoderma  and  rosacea. 

Mercury. — The  specific  action  of  mercury  in  syphilis  is 
fully  recognized,  but  to  get  the  best  results  from  its  admin- 
istration, the  state  of  the  patient,  the  proper  dosage,  and 
the  proper  method  of  its  employment  should  be  duly  con- 
sidered in  the  individual  case.  In  certain  cases  of  lichen 
planus  mercury  apparently  has  also  an  almost  specific 
influence.  The  value  of  the  drug  as  an  alterative  in  chronic 
eczema  and  as  an  intestinal  antiseptic  in  various  skin 
diseases,  notably  the  eczema  of  children,  may  also  be 
mentioned. 

Iodides. — Iodine  and  its  compounds  are  notably  of  value 
in  syphilis,  especially  in  the  later  stages,  but  it  also  has 
a  decided  beneficial  effect  in  actinomycosis  and  blasto- 
mycosis.  In  very  large  doses  it  has  been  recommended  in 
psoriasis,  but  we  believe  that  other  methods  of  treatment 
are  safer  and  speedier.  The  iodide  of  starch  has  been 
used  in  lupus  erythematosus. 

Mineral  Waters. — There  exists  a  deeply  grounded  faith 
in  the  efficacy  of  mineral  waters,  often  of  the  most  diverse 
chemical  characters,  in  the  treatment  of  skin  diseases,  but 
we  believe  that  any  favorable  influence  that  they  may 
exert  is  in  no  way  specific.  The  aperient  and  purgative 
waters  are  undoubtedly  useful  when  sluggishness  of  the 
bowels  or  constipation  exists,  and  the  various  alkaline 
waters  are  beneficial  where  an  alkaline  treatment  is  indi- 
cated. The  ferruginous  and  arsenical  waters  are  at  times 
similarly  advantageous.  However,  it  is  a  fact  of  experience 
that  these  same  waters  are  indubitably  more  efficacious 
drunk  at  the  springs,  conjoined  with  change  of  scene, 
freedom  from  care,  a  regulated  dietary,  and  other  well- 
recognized  influences,  than  when  taken  at  home. 

Recent  investigations  seem  to  make  it  probable  that  the 
waters  of -the  Hot  Springs  of  Arkansas  and  certain  other 
noted  springs  owe  their  virtues  to  the  presence  of  radio- 
activity. 


LOCAL  APPLICATIONS  505 

It  remains  to  add  that  water  as  such,  hot  or  cold,  drunk 
copiously  and  at  the  proper  times,  is  an  agent  of  inestimable 
value  in  many  morbid  conditions  of  the  system. 


LOCAL  APPLICATIONS. 

Powders. — Inert  dusting  powders  are  used  in  derma- 
tological  practice  to  afford  mechanical  protection  as 
between  opposed  surfaces  and  also  as  absorbents  and  mild 
astringents.  Such  powders  may  be  of  either  vegetable 
or  animal  origin  and  are  represented  by  rice,  starch, 
arrowroot,  lycopodium,  zinc  oxide,  chalk,  magnesium 
carbonate,  the  infusorial  earths,  etc.  Pautrier  states  that, 
generally  speaking,  mineral  powders  should  be  preferred 
to  those  of  vegetable  nature  as  less  liable  to  change  when 
brought  in  contact  with  the  cutaneous  secretions. 

The  active  powders,  such  as  iodoform,  aristol,  xeroform, 
salicylic  acid,  camphor,  alum,  calomel,  etc.,  have  caustic, 
reducing,  astringent  or  antipruritic  properties  according 
to  their  composition.  Powders  are  also  used  in  the  prep- 
arations of  pastes. 

It  is  essential  that  powders  should  be  triturated  to 
extreme  fineness  and  be  absolutely  without  grittiness.  As 
a  rule,  powders  are  contra-indicated  when  there  is  free 
discharge. 

Powders  may  be  applied  with  an  ordinary  powder  puff, 
or,  better  still,  with  a  pledget  of  absorbent  cotton,  or  put 
in  little  quilted  bags,  which  can  be  constantly  worn.  The 
perforated  tin  is  also  a  well-known  method  of  dredging 
a  surface  with  powder. 

]$ — Zinci  oxidi oij 

Pulv.  sem.  lycopodii 3vj — M. 

S. — An  absorbent  powder. 

1^— Pulv.  amyli 5yj 

Zinci  oxidi .  Sjss 

Pulv.  camphorse oss — M. 

S. — An  antipruritic  powder. 


506    GENERAL  TREATMENT  AND  METHODS 

fy — Thymolis  gr.  j 

Pulv.  zinci  oleatis 5j— M. 

S. — An  astringent  powder. 

1$ — Xeroformi 3ss 

Talci         Sivss— M. 

S. — An  antiseptic  powder. 

Lotions. — Lotions  are  of  great  value  in  the  treatment  of 
skin  diseases,  especially  those  of  a  superficial  inflammatory 
type,  e.  g.,  urticaria,  the  erythemata,  erythematous  and 
papular  eczema,  lichen  planus,  as  well  as  in  acne,  alopecia, 
and  some  of  the  parasitic  affections. 

They  may  be  divided  into  soothing,  astringent,  anti- 
pruritic,  stimulating,  antiseptic.  Pharmaceutically,  lotions 
are  weak,  medicated  solutions  or  mixtures.  Soothing  and 
slightly  astringent  lotions  are  perhaps  more  widely  em- 
ployed than  the  others,  and  contain  lead,  opium,  boric 
acid,  bicarbonate  of  sodium,  oxide  of  zinc,  and  calamine 
in  suspension,  dissolved  or  mixed  in  a  menstruum  of 
water,  water  and  glycerin,  liquor  calcis,  or  liquor  calcis 
and  oil  of  sweet  almonds. 

Certain  of  the  soothing  and  astringent  lotions  holding 
powders  in  suspension  are  too  drying,  and  this  objectionable 
quality  should  be  obviated  by  the  addition  of  small  quanti- 
ties of  glycerin,  2  to  10  minims,  to  1  oz. 

Astringent  Lotions  are  mainly  employed  in  derangements 
of  the  secretory  apparatus  and  in  hemorrhagic  conditions 
and  contain  tannin,  alum,  iron,  acetic  acid,  formalin,  ergot, 
and  drugs  having  a  similar  action. 

Stimulating  Lotions  contain  cantharides,  sulphur,  tar, 
thymol,  resorcin,  menthol,  ichthyol,  phenol,  and  such  like 
remedies.  They  find  their  principal  use  in  acne,  rosacea, 
papular  eczema,  psoriasis,  and  seborrhea,  especially  of  the 
scalp  in  the  last-mentioned  disorders. 

Lotions  are  usually  dabbed  on  the  surface  with  muslin 
or  cheese-cloth  mops.  Absorbent  cotton  should  not  be 
used  as  a  mop,  as  it  takes  up  too  much  of  the  lotion  and 
holds  it.  Where  extensive  surfaces  are  involved,  as  in 
dermatitis  venenata  and  acute  vesicular  and  erythematous 


LOCAL  APPLICATIONS  507 

eruptions,  certain  lotions  like  the  zinc  oxide  and  calamine 
preparation  may  be  advantageously  applied  on  strips  of 
cheese-cloth,  the  whole  kept  in  place  with  a  roller  bandage. 

!$ — Liq.  plumbi  subacetatis rr\x 

Liq.  carbonis  detergentis 3j 

Aq.  destillatae q.  s.  ad     Oj — M. 

S. — A  soothing  and  slightly  stimulating  lotion.     Hutchinson. 

3$ — Saponis  viridis giv 

Alcoholis  diluti gij 

M.  cola,  et  adde 

Spt.  lavandulse 5j 

S. — Shampoo. 

Equal  parts  of  Bagoe's  green  soap  and  cologne  make  a  more 
elegant  preparation.  Hebra. 

T$ — Acidi  carbolici 3ij-3iv 

Glycerini 3JJ-5J 

Aquae q.  s.  ad  Oj — M. 

S. — Antipruritic  lotion.    Use  as  a  spray.    , 

!$ — Zinci  oxidi §ss 

Pulv.  calamin.  praep 9iv 

Glycerini 3ij-3iv 

Liq.  calcis q.  s.  ad     5viij — M. 

S. — A  soothing  and  slightly  astringent  lotion. 
Distilled  or  rose  water  may  be  substituted  for  the  lime-water. 
Menthol  and  carbolic  acid  may  be  added,  the  menthol  being  first 
dissolved  in  alcohol  if  lime-water  is  used.     Boric  acid  is  also  a 
valuable  addition.  Startin. 

T$ — Tr.  cantharidis 3vj 

Glycerini 3ij 

Aceti  destillati 5ss 

Tr.  nucis  vomicae 3ss 

Aquae  rosae q.  s.  ad  5vj — M. 

S. — Stimulating  lotion  for  the  hair.  Tilbury  Fox. 

1$ — Resorcini oss 

Hydrarg.  chlor.  corrosiv gr.  ij 

Glycerini oj 

Spt.  odorati        5ij 

Aq.  destillatae q.  s.  ad  Sviij — M. 

S. — An  antiseptic  lotion  for  the  scalp.  Whitfield. 

Ointments. — A  large  number  of  diseases  of  the  skin  are 
best  treated  by  means  of  ointments. 

Ointment  bases  are  very  various,  but  the  more  usual  are 
lard,  freshly  prepared  petrolatum  (vaselin),  unguentum 


508          GENERAL  TREATMENT  AND  METHODS 

aquse  rosse  (cold  cream),  and  lanolin.  Spermaceti,  wax, 
oils,  suet  are  used  in  different  proportions  as  modifying 
agents.  A  large  number  of  proprietary  preparations  have 
also  been  brought  forward,  but  for  all  practical  purposes, 
vaselin,  especially  the  white  variety,  is  the  most  satis- 
factory. Lanolin  is  too  stiff  used  alone,  but  should  be 
softened  with  oil  of  sweet  almonds  or  cold  cream. 
Unguentum  aquse  rosse  is  a  valuable  ointment  base,  and 
from  its  power  of  facilitating  evaporation  (Unna)  is  very 
cooling  to  the  inflamed  skin. 

Ointments  may  be  conveniently  divided  into  two  main 
classes,  viz.,  soothing  and  stimulating,  the  first  class  com- 
prising cold  creams,  zinc  and  diachylon  ointments,  prepa- 
rations of  lanolin,  water  and  oil,  cocoa  butter,  and 
spermaceti,  etc.,  while  stimulating  ointments  contain  tar, 
sulphur,  mercury,  chrysarobin,  ichthyol,  salicylic  acid,  and 
similar  agents. 

In  nearly  all  cases  soothing  salves  should  be  spread  on 
suitable  strips  of  cotton  cloth,  canton  flannel,  or  patent  lint, 
and  neatly  bound  on  the  parts.  Cheese-cloth  and  linen 
should  never  be  used  for  this  purpose,  since  in  a  short 
period  the  ointment  rapidly  disappears  from  the  cloth,  and 
leaves  the  parts  covered  only  by  a  slightly  greasy  and 
crumpled  rag.  On  the  other  hand,  when  stimulation  or 
penetration  is  desired,  the  ointments  should  be  worked  in 
with  the  fingers  or  covered  by  some  impervious  substance 
like  rubber  tissue. 

We  are  indebted  to  Professor  J.  M.  Good,  of  the  St. 
Louis  College  of  Pharmacy,  for  the  appended  note  on  the 
preparation  of  ointments: 

"The  vehicles  with  which  the  active  medicinal  agents  are 
to  be  combined  are  various. 

"Some  are  fluid,  others  soft  solids,  and  others  of  quite 
firm  consistency,  but  even  the  firmest  of  them  have  melting 
points  much  below  the  temperature  at  which  water  boils. 
Examples  of  this  class  are  wax,  spermaceti,  and  the  hard, 
solid  paraffin. 

"These  should  be  fused  (melted)  by  the  heat  of  a  water 


LOCAL  APPLICATIONS  509 

bath.  Vegetable  or  animal  organic  matter  is  liable  to  be 
decomposed  by  the  play  of  a  flame  directly  upon  the  vessel 
containing  it. 

"Usually,  mixtures  composed  of  ingredients  of  different 
melting  points  require  to  be  constantly  stirred  while  cooling, 
otherwise  the  least  fusible  will  separate  in  hard,  granular 
particles  and  the  ointment  will  be  rough  and  unsatis- 
factory. 

"Exceptions  to  the  rule  are  melted  mixtures  of  rosin, 
yellow  wax,  lard  or  petrolatum,  and  paraffin  melted 
together.  These  should  be  allowed  to  cool  without  being 
disturbed,  otherwise  granular  mixtures  will  result. 

"More  or  less  water  may  be  incorporated  mechanically 
with  an  ointment.  This  may  be  accomplished  by  stirring 
the  mixture  as  it  cools  and  thickens. 

"Substances  of  a  saline  character  should  first  be  dissolved 
in  the  minimum  amount  of  water  required,  by  the  aid  of 
a  gentle  heat,  and  then  incorporated  with  the  remainder 
of  the  ointment.  Insoluble  substances,  either  vegetable 
drugs,  or  chemicals,  should  be  reduced  to  an  impalpable 
powder  by  trituration  before  being  incorporated  with  the 
ointment  base. 

"If  this  precaution  be  not  observed,  no  amount  of  subse- 
quent rubbing  of  the  mixture  will  produce  a  smooth  oint- 
ment. Some  substances,  such  as  powdered  opium,  extract 
of  opium,  red  oxide  of  mercury,  etc.,  may  be  reduced  by 
trituration  with  water.  Oxide  of  zinc  should  be  rubbed 
with  a  small  portion  of  the  ointment  until  the  mixture  is 
entirely  free  from  grittiness,  before  the  main  bulk  of  the 
fatty  base  is  added. 

"Aristol  and  chrysarobin  should  be  reduced  by  trituration 
with  liquid  petrolatum.  The  skilful  manipulator  will  bring 
to  his  aid,  in  such  work,  his  knowledge  of  solvents,  such  as 
are  bland  and  neutral,  and  by  this  means  save  himself 
much  labor  and  secure  the  best  results. 

"If  muscular  energy  be  needed,  however,  he  must  not 
spare  himself.  Too  often  it  is  thought  simple  mixing  is 
all  that  is  required.  One  whose  business  it  is  to  prepare 


510    GENERAL  TREATMENT  AND  METHODS 

ointments  should  not  be  allowed  thus  to  deceive  himself 
and  others. 

"Stock  ointments  should  be  stored  in  a  cool  place,  and 
those  which  are  liable  to  become  rancid  soon  should  not 
be  prepared  in  quantity. 

"There  are  but  few  ointments  the  preparation  of  which 
require  more  time  than  the  compounding  of  an  ordinary 
prescription." 

1$ — White  wax 200  gm. 

Benzoinated  lard 800  gm. — M. 

S. — Simple  ointment.  U.  S.  P. 

R, — Aquae  rosae, 

Olei  amygdalae  . aa     10.0 

Cerae  albas, 

Cetacei aa      1.0— M. 

S. — Cold  cream.  Jamieson. 

T$ — Acidi  borici, 
Cerse  albae, 

Paraffin   .      .  aa  10.0 

Olei  amygdalae  dulcis 10.0 — M. 

S. — Soothing  ointment.  H.  Hebra. 

R, — Olei  amygdalae  dulcis, 

Aquas aa     3j 

Lanolini 3vj — M. 

S. — Soothing  salve.  Also  an  acceptable  basis  for  zinc  oxide 
bismuth,  etc.  Jamieson. 

R, — Plumbi  oxidi 3iij-3vj 

Olei  olivarum 5xv 

Olei  lavandulae 3ij 

Aquae q.  s. — M. 

Bulkley  gives  the  following  direction:  Add  the  oil  to  two  pounds 
of  water,  and  heat  with  constant  stirring;  the  litharge  is  to  be 
slowly  sifted  in  while  it  is  well  stirred.  Stir  until  cold  and  then  add 
the  lavender. 

S. — Soothing  and  astringent  ointment.  Hebra. 

R, — Bismuth!  oxidi gr.  xv 

Acidi  oleici 3|j 

Cerae  albas 3jss 

Vaselini 3ivss 

Olei  ros83 TTLJ — M. 

Rub  up  the  bismuth  with  the  oleic  acid  and  let  stand  for  two 
hours;  then  place  in  a  water  bath,  add  the  vaselin  and  wax,  and 
stir  until  cold;  finally  add  the  oil  of  rose. 

S. — Soothing  ointment.  Anderson 


LOCAL  APPLICATIONS  511 

1$ — Emplastri  plumbi, 

Vaselini aa  gviij — M. 

Melt  together  with  constant  stirring  and  add 

Oil  of  geranium q.  s. 

The  lead  plaster  used  should  be  free  of  glycerin. 
S. — Unguentum  vaselini  plumbicum.     Soothing  ointment. 

Piffard. 

1$ — Spermaceti 125  gm. 

White  wax 120  gm. 

Expressed  oil  of  almond 560  gm. 

Sodium  borate 5  gm. 

Stronger  rose-water 1000  gm. — M. 

S. — Ointment  of  rose-water.     When  the  ointment  is  used  as  a 

vehicle  for  metallic  salts  omit  the  sodium  borate.  U.  S.  P. 

T$ — Zinci  carbonatis 3j 

Acidi  salicylici gr.  x 

Vaselini         3j 

Ung.  aquse  rosse §j — M. 

S. — Soothing  ointment.  Jamieson. 

]$ — Boroglycerini 5ij 

Cerae  albse, 

Cetacei aa  3j 

Vaselini 3vj — M. 

S. — Soothing  ointment.  Duhring. 

1$ — Hydrarg.  ammoniati 3j 

Liq.  carbonis  detergentis 3j 

Ung.  aquse  rosse 5j — M. 

S. — Stimulating  ointment. 

1$ — Acidi  salicylici 9j 

Sulphuris  prsecip 3j-3ij 

Vaselini 5j 

Olei  limonis q.  s. — M. 

S. — Stimulating  ointment. 

I$— Olei  rusci 3j-5ij 

Ung.  aquse  rosse 5j — M. 

S. — Stimulating  ointment. 

1$ — Acidi  carbolici gr.  v 

Pulv.  acidi  tannici 3ss 

Glyc.  acidi  tannici 3ss 

Ung.  aquae  rosse 5j — M. 

S. — Astringent  ointment.  Bulkley. 

Pastes. — ^These  are  local  applications  consisting  of  fatty 
matter  of  various  consistencies  such  as  adeps  lanse,  lanolin, 


512    GENERAL  TREATMENT  AND  METHODS 

vaselin,  lard,  olive  oil  and  linseed  oil,  and  some  inert  powder 
in  large  quantity,  even  up  to  50  per  cent.,  such  as  starch, 
zinc  oxide,  and  certain  earths. 

Pastes  are  of  value  on  account  of  their  adhesiveness  and 
porosity,  but,  as  a  rule,  are  unsuited  for  weeping  surfaces. 

Pastes  generally  act  more  effectively  when  spread  on 
cloth  and  bound  to  the  affected  parts  with  a  roller  bandage, 
but  in  many  situations,  and  in  small  patches  of  eruption, 
it  is  sufficient  to  smear  the  preparation  on  gently  and  quite 
thinly  with  the  fingers.  The  same  general  rules  as  to  the 
making  of  ointments  (vide  supra)  hold  equally  well  for  the 
preparation  of  pastes.  There  are  many  formulae  for  these 
pastes  (gum,  dextrin,  kaolin,  lead,  and  glycerin)  but  the 
following  examples  are  sufficiently  typical : 

1^ — Zinci  oxidi, 

Pulv.  amyli aa  5ss 

Vaselini 5j — M. 

This  may  be  medicated  with  salicylic  or  boric  acid.  Lassar. 

1$ — Acidi  borici 3j 

Pulv.  amyli, 

Zinci  oxidi aa     3ij 

Vaselini 5j— M. 

Duhring. 

1$ — Terrse  silicise 3ss 

Sulphuris  prsecipitati 5ij 

Zinci  oxidi 3jss 

Adipis  benz 5j — M. 

Unna. 

1^ — Acidi  salicylici gr.  x 

Pulv.  amyli, 

Bismuthi  subnitratis aa     3jij 

Ung.  aquae  rosae q.  s.  ad     5j — M. 

G.  H.  Fox. 

1$ — Resorcini gr.  x-xx 

Zinci  oxidi, 
Pulv.  amyli, 
Vaselini, 

Lanolini aa     3ij — M. 

Ihle. 

Salve  Pencils. — Salve  pencils  and  paste  pencils  are  but 
little  used  in  this  country.    They  are  designed  to  furnish  a 


LOCAL  APPLICATIONS  513 

cleanly  and  ready  method  of  applying  the  required  drugs 
in  acne,  psoriasis,  ringworm,  etc.  The  base  recommended 
for  the  salve  pencils  by  Unna  is  a  mixture  of  lanolin  and 
wax,  or  lanolin,  wax,  and  cocoa  butter.  Audrey  advises 
for  the  same  purpose  a  combination  of  cocoa  butter,  par- 
affin, and  olive  oil.  Paste  pencils  contain  no  fat  and  are 
readily  soluble.  The  base  consists  of  starch,  tragacanth, 
gum  arabic,  sugar,  etc. 

The  alcohol  pencils  and  the  resinous  pencils  may  be 
mentioned  in  this  connection. 

1$ — Sulphuris  prsecip 3ij 

Cerse 3ij 

Adipis  lanae 3iv — M. 

Unna. 

1$ — Chrysarobini 9ij 

Olei  theobrom 5v 

Paraffin 3ij 

Olei  olivae 9j — M. 

Audrey. 

Gly co gelatins. — Pick  first  suggested  the  use  of  gelatin 
as  a  vehicle  for  remedies  employed  in  cutaneous  practice. 
His  method  of  preparation  was  subsequently  greatly  im- 
proved by  Unna,  who  combined  the  gelatin  and  glycerin 
directly  instead  of  painting  the  latter  over  the  gelatin  after 
it  was  put  on  the  skin.  The  glycerin  jellies  are  very 
valuable  preparations;  they  relieve  congestion,  are  anti- 
pruritic,  and  make  a  certain  elastic  compression  on  the  skin. 
According  to  Liestikow  they  even  accelerate  the  evapora- 
tion of  the  cutaneous  secretions.  Various  drugs  in  certain 
proportions  may  be  added  to  the  formulae  given  below, 
especially  sulphur  and  ichthyol.  These  prepaiations  are 
made  ready  for  use  by  being  placed  in  a  tin,  which  in 
turn  is  set  in  a  vessel  of  boiling  water.  The  jelly  is  painted 
on  with  a  stiff  brush,  and  then  covered  with  tissue  paper 
or  a  thin  layer  of  absorbent  cotton.  It  is  very  important 
that  any  surface  thus  treated  should  be  first  cleaned  with 
an  antiseptic  solution  suitable  to  the  case  in  hand. 
33 


514    GENERAL  TREATMENT  AND  METHODS 

1$ — Gelatini, 

Zinci  oxidi aa  3j 

Glycerin! gr.  c 

Aquae 5iij — M. 

1$ — Zinci  oxidi, 
Gelatini, 
Glycerini, 

Aquae aa     pts.  aeq. 

The  gelatin  is  laid  in  a  dish  and  water  poured  over  it.  It  is  fre- 
quently turned  until  every  part  has  taken  up  water  and  become 
supple.  It  is  then  melted  in  a  water  bath,  and  the  glycerin  previously 
mixed  with  the  zinc  oxide,  and  any  other  desired  drug,  is  stirred  in. 

Xorman  Walker. 

Plasters. — Plasters  are  topical  applications,  variously 
medicated,  having  a  resinous  or  fatty  base,  and  are  designed 
for  close  and  continuous  use  on  the  skin.  The  official 
plasters  find  little  employment  in  cutaneous  practice,  with 
the  exception  of  the  emplastrum  hydrargyri,  while  diachy- 
lon plaster  is  used  in  the  preparation  of  diachylon  ointment. 
Certain  unofficial  plasters,  such  as  the  salicylated  soap 
plasters  of  Pick  and  Klotz,  mentioned  in  other  parts  of 
this  work,  are  extremely  valuable. 

A  number  of  years  ago  Unna  suggested  the  use  of  plaster 
mulls,  which  are  made  of  gutta-percha  cloth  and  spread 
with  the  required  medicament.  As  manufactured  in  Ger- 
many, they  are  very  elegant  preparations,  and  can  be 
obtained  in  almost  endless  combinations.  We  have  found 
the  salicylic  acid  and  the  carbolic-mercury  plasters  to  be 
the  most  useful. 

The  salve  mulls  are  made  by  incorporating  the  desired 
remedy  with  a  base  of  benzoated  suet  and  lard,  whicli  is 
then  spread  on  one  or  both  sides  of  muslin : 

1$ — Hydrargyri 3jy 

Olei  terebinthinae 3ij 

Cerae  flav 3iij 

Em  pi.  plumbi 3jss — M. 

S. — Spread  on  muslin.  German  formula. 

1$ — Empl.  plumbi 3xxv 

Pulv.  saponis 3iv 

Aquae <j.  s. 

Vaselini 3v 

Camphorae gr.  xx 

Acidi  salicylici 2)v — M. 

S. — Spread  on  muslin 


LOCAL  APPLICATIONS  515 

1$  —  Picis  burgundicae       .......  5x 

Cerae  flav., 

Resinaa       ....     V     ....  aa  3iv 

Olei  terebinthinse       .......  3ij 

Balsami  canadensis  .......  Sss  —  M. 

A  vehicle  for  pyrogallol  and  resorcin.  Duhring. 

IJ  —  Empl.  saponis  liq  ........ 

Olei  olivse        ......... 


Acidi  salicylici      ........     gr.  xxxvij  —  M. 

S.  —  Spread  on  muslin.  Pick. 

Caustics.  —  These  agents  are  employed  in  dermatological 
practice  principally  for  the  destruction  of  new  growths, 
such  as  lupus  and  epithelioma,  and  also  for  the  removal 
of  warts,  moles,  and  hypertrophic  conditions  generally. 
Since  the  introduction  of  the  galvanocautery,  the  Paquelin 
cautery,  electrolysis,  and  the  arrays,  the  so-called  potential 
or  chemical  caustics  are  not  resorted  to  as  much  as 
formerly. 

Among  the  principal  caustics  may  be  mentioned  caustic 
potash,  chloride  of  zinc,  chromic  acid,  nitric  acid,  the  acid 
nitrate  of  mercury,  pyrogallol,  lactic  acid,  trichloracetic 
acid,  and  nitrate  of  silver.  Some  of  these  preparations, 
like  caustic  potash,  for  example,  are  painful  and  deeply 
penetrating,  and  need  the  greatest  care  in  their  use,  while 
arsenic  has  a  selective  action  on  the  diseased  tissue  ;  others, 
like  trichloracetic  acid,  the  acid  nitrate  of  mercury,  nitric 
acid,  and  the  nitrate  of  silver,  if  judiciously  employed, 
cause  only  superficial  destruction. 

1$  —  Pyrogallol      ..........      3ijss-3iij 

Acidi  salicylici    .........      gr.  xxy-1 

Cerat.  simplicis  .........      3j-5ij 

Petrolati        .......      q.  s.  ad  5]  —  M. 

S.  —  Spread  on  lint.    For  epithelioma.  Stelwagon. 

1$  —  Acidi  arsenosi, 

Acacise  pulv  .........   aa     3ij 

Orthoform     ..........      3ss  —  M. 

Make  into  a  paste  with  a  little  water.  Norman  Walker. 

1$  —  Hydrarg.  sulphuret  rub  .......      3ss 

Ung.  aquae  rosse       ........      Sss  —  M. 

S.  —  Spread  on  muslin.  Hebra-Cosme. 


516    GENERAL  TREATMENT  AND  METHODS 


T$ — Farinse  tritici, 

Amyli fifi      .~»j 


Acidi  arsenosi     . 
Hydrarg.  sulph.  rub. 
Ammonii  chloridi    . 
Hydrarg.  bichloridi 
Zinci  chloridi  cryst. 
Aquas  bullientis 


gr.  vnj 
gr.  xl 
gr.  xl 
gr.  iv 


Sj 


M. 


All  the  ingredients  except  the  zinc  and  water  are  finely  ground 
together.  The  zinc  is  then  dissolved  in  the  water  and  this  is  poured 
upon  the  powder,  stirring  all  the  time.  Let  it  stand  for  twenty-four 
hours.  Bougard. 

Poultices. — Linseed  meal  and  bread  poultices,  although 
still  much  employed  by  the  laity,  are  now  practically  given 
up  in  medical  practice,  since  they  favor  the  growth  of 
organisms  and  do  more  harm  than  good.  Hot  borated 
and  carbolized  compresses  are  now  used  for  surgical 
purposes,  but  for  the  removal  of  scales  and  crusts  the 
boric-acid  starch  poultice  remains  a  useful  application. 
Norman  Walker  gives  the  following  direction  for  making 
the  boric  starch  poultice:  1  teaspoonful  of  boric  acid 
is  mixed  with  4  tablespoonfuls  of  cold-water  starch 
(wheaten)  and  enough  cold  water  to  bring  the  mixture  to 
the  consistency  of  cream;  1  pint  of  boiling  water  is  then 
gradually  added,  the  mixture  being  constantly  stirred  until 
the  starch  bursts  and  a  translucent  jelly  results.  When 
this  is  cold  the  amount  required  is  spread  on  a  cloth  to  the 
thickness  of  one-half  inch,  which  in  turn  is  covered  with 
muslin  and  applied  to  the  part. 

Oils  and  Liniments. — Oils,  such  as  olive  oil,  almond  oil, 
and  linseed  oil,  are  used  to  remove  crusts  and  scales  and 
also  to  soothe  and  protect  the  inflamed  skin.  Other  oils 
are  added  to  medicinal  preparations  for  soothing  and 
softening  purposes  or,  in  a  pure  or  diluted  state,  utilized 
therapeutically,  e.  g.,  tar,  chaulmoogra  and  gurjun  oil, 
castor  oil,  and  petroleum  oil.  Olive  oil  or  linseed  oil  in 
combination  with  lime-water  forms  the  valuable  carron  oil. 
The  calamine  liniment  of  Crocker  is  a  remedy  of  great 
usefulness  in  extensive  eruptions  of  a  certain  type,  as, 
for  example,  pityriasis  rubra,  bullous  eruptions,  and  moist 
eczema. 


LOCAL  APPLICATIONS  517 

!$ — Acidi  carbolici n\xx 

Olei  amygdalae  dulcis, 

Liq.  calcis  aa     5ij— M. 

S- — Apply  to  scalp  with  medicine  dropper  in  acute  eczema. 

1$ — Pulv.  calaminae  prsep £)j 

Zinci  oxidi gr.  xv 

Liq.  calcis, 

Olei  amygdalae  dulcis  ....       q.  s.  ad      5j — M. 

Skinner. 

!$ — Pulv.  calaminse  praep Qij 

Zinci  oxidi 3SS 

Olei  olivae, 

Liq.  calcis .   aa  5j— M. 

This  is  greatly  improved  by  the  addition  of  one  or  two  drachms 
of  lanolin.  Crocker. 

1$ — Olei  petroleii 5  parts 

Olei  olivae 1\  parts 

Balsam  peruv 1  part — M. 

S. — In  pediculosis.  Kaposi. 

Soaps. — Soaps  are  chemical  combinations  of  the  fatty 
acids  with  an  alkali.  They  are  divided  into  hard  (soda) 
and  soft  (potash)  soaps.  Hard  soaps  are  used  for  cleansing 
and  toilet  purposes,  and  really  should  be  neutral  in  char- 
acter. Unna  was  the  first  to  introduce  the  superfatted 
soap,  which  contains  the  fat  in  excess.  Various  medica- 
ments are  added  to  soaps  for  therapeutic  purposes,  but, 
with  some  exceptions,  do  not  give  as  satisfactory  results 
as  do  the  same  drugs  used  in  some  other  form.  Soft  or 
potash  soap,  commonly  called  sapo  viridis,  or  green  soap, 
is  exceedingly  valuable  in  practice.  It  is  an  admirable 
cleansing  agent,  besides  being  stimulating  and  mildly 
caustic.  It  is  much  employed  in  psoriasis,  seborrhea  of 
the  scalp,  in  thickened  eczemas,  and  lupus  erythematosus. 
It  is  often  introduced  into  ointments  to  increase  their 
effect,  and  is  a  good  vehicle  for  tar. 

Hebra's  spiritus  saponis  kalinus,  which  consists  of  2 
parts  of  green  soap  and  1  part  of  alcohol,  scented  with 
spirits  of  lavender,  makes  an  excellent  shampoo. 

Paints  and  Varnishes. — These  are  local  applications  of 
a  fluid  or  semisolid  nature,  which  dry  on  the  skin  and 
leave  a  thin  layer  of  the  incorporated  drug. 


518    GENERAL  TREATMENT  AND  METHODS 

Paints  or  pigments  made  with  collodion  or  traumaticine 
are  very  useful  preparations  in  the  treatment  of  various 
diseases.  Tar,  chrysarobin,  pyrogallol,  and  salicylic  acid 
are  the  drugs  usually  employed.  Traumaticin  is  a  10  per 
cent,  solution  of  gutta-percha  in  chloroform.  In  adding  an 
oil  to  collodion  the  contractile  variety  of  the  latter  should 
be  prescribed,  since  an  addition  of  oil  to  the  flexible  kind 
will  make  it  hyperflexible. 

The  soluble  varnishes  made  of  various  substances,  gel- 
atin, glycerin,  tragacanth,  etc.,  that  are  readily  washed 
from  the  skin,  are  cooling,  antipruritic,  and  protective: 

3$ — Tragacanthae, 

Glycerini       . aa  3iv 

Boracis 3ss 

Aquae  destillatae q.  s. — M. 

This  is  the  original  of  all  similar  preparations.  Provan. 

R — Olei  cadini 3j 

Collodii 5j— M. 

A  tar  paint. 

R — Tragacanthae      .  3jjss 

Gelatin,  opt. 


Glcerini 


- 

3vj 


Thymolis       .      . 

Aquae  destillatae  q.  s. — M. 

Place  the  tragacanth  and  gelatin  each  in  10  oz.  of  water  in  covered 
jars  and  make  the  final  quantity  up  to  12  oz.  To  this  paste  may  be 
added  resorcin,  salicylic  acid,  and  most  other  drugs  except  subacetate 
of  lead.  Skinner-Unna. 

R — Chrysarobini gr.  xlv 

Acidi  salicylici gr.  xlv 

Traumaticini §j — M. 

A  traumaticine  paint. 

R — Tragacanthae gr.  xxv 

Glycerini Trptxx 

Aquae 3xxvss — M. 

To  this  may  be  added  zinc  oxide,  carbolic  acid,  etc.          Pick. 

R — Bassorin ojss 

Dextrin 3vj 

Glycerini 3ij 

Aquae q.  s.  ad  3xxvss — M. 

This  may  be  variously  medicated.  Elliot. 


LOCAL  APPLICATIONS  519 

1$ — Acetanilide 3j 

Zinc  oxide 5iij 

Iodized  starch,  5  per  cent 3iv — M. 

S. — Add  sufficient  water  or  liquid  vaselin  to  make  a  paint.  Use 
as  an  antiseptic.  Lusk. 

Baths. — Baths  are  not  so  frequently  employed  in  the 
treatment  of  skin  diseases  as  in  former  years,  having  been 
largely  replaced  by  other  measures.  Baths  are  often  posi- 
tively harmful  in  acute  eczema  and  pyogenic  affections, 
and  in  our  experience  the  warm  bath,  while  temporarily 
allaying  the  itching  in  pruritus  and  urticaria,  decidedly 
increases  the  discomfort  afterward. 

Warm  baths,  medicated  or  plain,  alkaline  or  emollient, 
are  useful  as  cleansing  and  soothing  agents  in  psoriasis, 
ichthyosis,  lichen  planus,  and  similar  disorders,  and  the 
permanent,  general  bath  as  recommended  by  Hebra  is 
valuable  in  pemphigus  and  extensive  burns.  Tar  baths 
are  used  in  psoriasis  and  chronic  eczema  (the  patient  being 
first  tarred  before  getting  into  the  bath,  or  else  plunged  into 
a  bath  containing  an  emulsion),  and  the  mercurial  bath  is 
prescribed  in  syphilis,  especially  for  children.  Sulphur 
baths  may  be  employed  in  scabies,  and  a  solution  of  sodium 
permanganate  added  to  a  bath  is  curative  in  pityriasis  rosea. 
Sea  bathing  is  generally  harmful  in  eczema,  although  salt 
sponge  baths  are  an  excellent  adjuvant  in  the  treatment 
of  acne,  and  according  to  some  authorities  in  dry,  itching 
eczema.  The  sulphur  and  other  baths  obtainable  at  the 
springs,  here  and  abroad,  owe  much  of  their  influence  to 
the  mental  effect  of  change  of  scene,  habits,  etc.,  rather 
than  to  any  especial  virtue  of  their  own. 

The  following  formulae  for  baths  were  suggested  by 
Tilbury  Fox.  They  also  have  the  endorsement  of  Rad- 
cliffe-Crocker.  The  quantity  of  water  in  a  bath  is  esti- 
mated at  30  gallons  with  a  temperature  of  90°  to  95°  F. 

Soothing  and  Emollient  Baths. — The  amounts  to  be  used 
are  either — of  bran,  2  to  6  Ibs.;  of  gelatin,  £  to  3  Ibs.;  of 
size,  2  to  4  Ibs.;  of  linseed,  1  lb.;  or  of  starch,  1  Ib.  The 
starch  should  be  first  beaten  through  a  small  quantity  of 
water  before  filling  the  bath. 


520    GENERAL  TREATMENT  AND  METHODS 

Alkaline  Bath. — This  is  made  by  the  addition  of  2  to  10 
oz.  of  the  carbonate  of  sodium  or  carbonate  of  potassium, 
or  3  oz.  of  borax.  Bran  liquor  may  be  added  with  advan- 
tage. Used  in  urticaria,  chronic  eczema,  psoriasis,  prickly 
heat,  and  lichen. 

Acid  Baths. — Add  to  the  bath  1  oz.  of  nitric  or  hydro- 
chloric acid,  or  1  oz.  of  each.  Used  in  chronic  pruriginous 
affections. 

Compound  Sulphur  Bath. — Precipitated  sulphur,  2  oz. ; 
hyposulphite  of  sodium,  1  oz. ;  water  1  pt.  (Startin).  Used 
in  scabies,  body  ringworm,  psoriasis,  etc. 

Mercurial  Baths. — Bichloride  of  mercury,  1  to  3  drachms; 
hydrochloric  acid,  1  drachm;  water,  1  pt.  For  children, 
take  7  to  30  gr.  of  the  bichloride  with  an  equal  quantity 
of  ammonium  chloride,  first  dissolved  in  some  hot  water, 
which  add  to  a  bath  containing  8  gal.  of  warm  water. 
Used  in  syphilis. 

Tar  Bath. — Oil  of  cade,  12^  drachms;  fluidextract  of 
quillaya,  1\  drachms;  yolk  of  egg,  1;  water  sufficient  to 
make  8  oz.  This  is  added  to  the  bath  after  first  mixing 
with  a  little  very  hot  water  and  vigorously  shaken.  Instead 
of  this  emulsion  the  patient  may  be  thoroughly  tarred  and 
allowed  to  soak  in  a  warm  bath  for  from  three  to  six  hours. 
Used  in  chronic  eczema,  psoriasis,  chronic  pemphigus,  etc. 

THE  OPSONIC  METHOD. 

The  gist  of  the  opsonic  method  may  be  stated  in  the 
following  propositions : 

1.  Nature  provides  certain  substances  capable  of  com- 
bating infections. 

2.  These  substances  are  produced   in  answer  to   the 
stimulus  furnished  by  the  presence  of  the  specific  toxin  in 
the  blood  or  tissues. 

3.  In  certain  cases  of  localized  infection,  toxins  do  not 
find  their  way  into  the  circulation  in  sufficient  quantity 
to   call   forth   enough   of   the   antagonistic   substance  or 
substances  to  combat  successfully  the  infecting  organism. 


THE  OP  SON  1C  METHOD  521 

4.  Introducing  the  specific  toxin  from  without  serves  to 
increase   the   amount   of   the   antagonistic   substance  or 
substances  in  the  serum. 

5.  If  the  amount  of  toxin  so  introduced  be  too  small,  it 
will  fall  short  of  its  object,  whereas  if  it  be  too  large  it 
only  adds  fuel  to  the  fire  and  may  change  a  local  into  a 
general  infection. 

6.  It  is,  therefore,  highly  desirable  to  determine  the  exact 
dose  of  toxin  required. 

7.  Among  the  various  antagonistic  substances  concerned, 
the  opsonins  allow  of  being  estimated  by  the  fact  that  they 
prepare  bacteria  for  ingestion  by  the  phagocytes.     The 
number  of  bacteria  ingested  by  a  given  number  of  phago- 
cytes, therefore,  indicates  the  proportion  of   the  opsonin 
present  in  the  serum. 

8.  The  opsonic  index  thus  determined  shows  the  dose  of 
toxin  required  to  provoke  a  response  in  the  way  of  the 
production  of  antagonistic  substances  sufficient  to  combat 
successfully  the  infection. 

9.  The  toxin  may  be  furnished  in  the  dose  thus  indi- 
cated in  the  shape  of  a  sterilized  and  standardized  sus- 
pension of  dead  bacteria  known  as  a  vaccine. 

10.  Any  localized  disease  caused  by  a  bacterium  which 
can  be  cultivated  outside  the  body  can  be  treated  by  this 
method. 

11.  This  treatment  is  not  so  well  adapted  to  systemic 
infections,  for  here  auto-inoculations  occur  spontaneously. 
Our  efforts  should  here  rather  be  directed  to  converting 
the  systemic  into  a  localized  infection,  after  which   the 
method  may  be  applied. 

12.  The  'method  may,  however,  be  of  use  in  certain 
generalized  infections,  since  the  artificial  inoculation  acting 
primarily  on  the  tissues,  instead  of  on  the  blood,  may  call 
out  a  larger  opsonic  response.     We  shall  attempt  a  brief 
exposition  of  the  chief  facts  on  which  these  propositions 
are  based.     Two  theories  have  been  advanced  to  account 
for  immunity,  the  one  accrediting  immunizing  power  to 
certain  cells  of  the  blood  and  the  other  to  the  serum. 


522    GENERAL  TREATMENT  AND  METHODS 

According  to  Metchnikoff,  certain  of  the  white  corpus- 
cles, which  he  named  phagocytes,  are  the  active  elements. 
Ehrlich,  on  the  other  hand,  holds  that  the  cells  of  the 
body  have  the  power  of  generating  and  casting  into  the 
blood  certain  substances  antagonistic  to  bacteria  or  their 
toxins. 

While  the  fact  is  clearly  established  that  certain  cells — 
the  polymorphonuclear  neutrophiles — can  and  do  ingest 
bacteria,  Sir  A.  E.  Wright  has  shown  that  they  can  only 
do  this  in  the  presence  of  certain  substances,  which,  by 
uniting  with  the  bacteria  and  paralyzing  them,  prepare 
them  for  being  ingested,  as  a  cook  prepares  food  for  the 
table.  These  are  the  opsonins  (Greek,  o^cavtu),  I  cook 
for).  Corpuscles  washed  free  of  plasma  will  ingest  no 
bacteria  until  serum  containing  an  opsonin  antagonistic 
to  those  bacteria  is  added. 

Whether  there  exists  a  separate  opsonin  for  each  bac- 
terium, or  only  one  common  opsonin,  has  not  yet  been 
definitely  settled. 

Sir  A.  E.  Wright  undertook  the  task  of  determining  the 
power  of  resistance  to  infection  possessed  by  the  organism, 
and,  therefore,  the  amount  of  toxin  required  to  call  forth 
the  degree  of  resistance  desired. 

According  to  Urwick: 

1.  The  opsonic  power  of  different  healthy  individuals 
is  nearly  the  same. 

2.  Their  opsonic  power  does  not  vary  from  day  to  day. 

3.  The  opsonic  power  of  individuals,  the  subjects  of 
general  infections,  may  be  either  high  (active  response)  or 
low  (a,  inherent  deficiency;  fe,  exhaustion). 

4.  Their  opsonic  power  varies  from  day  to  day,  showing 
positive  and  negative  phases  following  upon  a  series  of 
auto-inoculations. 

To  which  one  may  add: 

5.  The  opsonic   power  of  individuals  the  subjects  of 
localized  infections  is  often  low  because  the.  infection  is 
and  remains  localized — as  in  lupus,  that  may  last  a  life- 
time  without   becoming   generalized.      If    and   when    it 


THE  OPSONIC  METHOD  523 

becomes  generalized,  the  opsonic  power  will  become  high 
or  fluctuating. 

6.  A   low   opsonic   power  often   precedes   a   localized 
infection  and  is  its  predisposing  cause. 

7.  The  opsonic  power  of  the  lymph  within  an  area  of 
localized  infection  (e.  g.,  a  boil)  is  low,  while  that  of  the 
blood  may  be  relatively  high — simply  because  the  local 
supply  has  been  exhausted.     This  condition  is  remedied 
in  part  by  stimulating  a  more  rapid  local  circulation  of  the 
lymph,  as  by  poultices,  hot  fomentations,  phototherapy, 
etc. 

By  the  "  opsonic  index"  is  meant  the  proportion  which 
the  opsonic  power  of  the  blood  of  an  individual  bears  to 
that  of  the  blood  of  a  normal  person.  The  latter  is  taken 
as  the  standard  and  called  one.  The  opsonic  index  of  an 
infected  individual  may,  as  stated  above,  in  Urwick's 
third  conclusion,  be  either  one,  or  more  than  one,  or  less 
than  one,  according  as  the  toxin  or  the  immunizing  power 
is  gaining  the  ascendant. 

Soon  after  inoculation,  the  index,  according  to  Wright, 
falls  below  the  normal  (negative  phase),  later  it  rises 
above  the  normal  (positive  phase). 

Since  the  introduction  of  bacterial  toxins  into  the  blood 
stimulates  the  production  of  protective  substances,  Wright 
determined  to  do  the  same  thing  artificially  by  the  injection 
of  standardized  and  sterilized  suspensions  of  bacteria. 
These  he  calls  "vaccines."  By  their  use  a  low  index  can 
be  raised  to  normal  or  higher. 

Determination  of  the  Index. — The  following  must  be 
provided :  (1)  Washed  corpuscles  obtained  from  the  blood 
of  a  healthy  individual;  (2)  serum  from  the  infected 
individuals,  as  well  as  other  specimens  from  several  healthy 
individuals,  to  serve  as  standards  and  'controls;  (3)  an 
emulsion  of  the  bacteria  concerned  in  the  infection.  The 
manner  of  obtaining  and  preparing  these  reagents  need 
not  be  entered  into  here.  A  number  of  capillary  tubes  are 
filled  with  mixtures  each  consisting  of  one-third  bacterial 
emulsion,  one-third  corpuscles,  and  one-third  serum  taken 


524    GENERAL  TREATMENT  AND  METHODS 

from  each  of  the  specimens  to  be  investigated.  After  the 
mixtures  have  remained  one-quarter  hour  in  the  incubator, 
a  small  drop  from  each  is  spread  upon  a  slide  and  examined. 
The  number  of  bacteria  contained  in  any  given  number  of 
phagocytes,  mixed  with  serum  from  a  healthy  person,  is 
counted.  This  is  set  down  as  the  denominator  of  a  fraction, 
the  numerator  of  which  is  furnished  by  the  number  of 
bacteria  counted  in  an  equal  number  of  phagocytes  mixed 
with  the  serum  from  the  individual  under  investigation. 
This  fraction  expresses  the  opsonic  index  of  the  latter. 
Serum  is  accepted  as  a  standard  when  the  person  furnish- 
ing it  is  healthy  by  ordinary  tests,  and  when  his  opsonic 
index  agrees  with  that  of  the  other  apparently  healthy  in- 
dividuals taken  as  controls.  (See  Urwick's  first  conclusion.) 
This  is  sometimes  called  Wright's,  or  the  bacillary  index. 
Simon's,  or  the  percentage  index,  is  based  on  the  propor- 
tion of  leukocytes  found  which  contain  bacilli. 

The  Vaccines. — A  description  of  the  complicated  pro- 
cesses involved  in  the  preparation,  sterilization,  and  stand- 
ardization of  the  vaccines  would  be  out  of  place  in  a 
work  intended  for  the  practitioner.  The  vaccines  are 
"  autogenous,"  that  is,  they  are  cultivated  for  each  case 
from  the  patient's  own  bacteria.  They  consist  of  the  dead 
bodies  of  microorganisms  sterilized  by  heating  to  60°  C.  for 
one  hour.  The  dose  varies  with  the  condition  of  the  subject. 
The  dose  of  tuberculin  ranges  from  1  ^d  mg.  to  ^-g-g-  mg. ; 
that  of  staphylococcic  vaccine  contains  from  500,000,000 
to  2,500,000,000  dead  bacteria.  One  should  begin  with 
very  small  doses  and  be  governed  later  by  the  response  as 
shown  by  the  index. 

The  first  step  is  to  determine  the  opsonic  index  on  several 
different  days.  The  first  dose  of  vaccine  may  then  be  given 
and  the  index  again  determined  every  few  days.  The 
second  dose  is  given  a  little  after  the  positive  phase  (see 
above)  has  risen  a  little  above  the  index  determined  prior 
to  the  administration  of  the  vaccine.  This  will  usually 
be  in  about  ten  days,  although  the  time  may  be  shorter  or, 
again,  much  longer.  Later  intervals  will  be  of  about  the 


THE  OPSONIC  METHOD  525 

same  length,  the  injections  always  being  made  during  the 
positive  phase.  When  the  second  or  succeeding  injections 
are  made  too  soon,  or  if  the  dose  be  too  large,  the  negative 
phase  will  be  unduly  prolonged  and  accentuated,  mani- 
festing itself  clinically  by  fever,  malaise,  etc.,  and  perhaps 
permitting  the  local  infection  to  become  general. 

Wright  believes  that  the  protective  inoculation  is  best 
made  "  'up-stream'  from  the  focus  of  infection,  i.  e.,  in 
some  part  of  the  lymph  watershed  which  drains  through 
the  focus  of  infection,"  since  "  the  protective  substances 
which  are  produced  at  the  site  of  inoculation  may  be 
expected  to  come  into  application  on  the  focus  of  infec- 
tion in  a  comparatively  undiluted  condition." 

The  method  is  too  technical  ever  to  become  generalized 
among  practitioners.  Its  value  is  such,  however,  that  it 
will  doubtless  come  into  wide  use  among  those  who  can 
command  the  services  of  a  trained  bacteriologist.  Sir  A.  E. 
Wright,  the  originator  of  the  method,  uses  the  following 
language:  "I  do  not  hesitate  to  contend  that  we  have, 
in  the  power  of  raising  the  antibacterial  powers  of  the  blood 
with  respect  to  any  invading  microbe,  out  of  all  comparison 
the  most  valuable  asset  in  medicine." 

Attempts  to  simplify  the  method  have  been  made  in 
two  directions.  One  is  by  substituting  stock  vaccines  for 
the  autogenous  cultures.  The  results  so  obtained  are  far 
inferior  to  those  yielded  by  the  original  method.  The  other 
consists  in  making  but  one  opsonic  determination  before 
the  first  vaccination,  the  patient's  clinical  condition  fur- 
nishing the  indication  for  later  vaccinations.  Varney,  of 
Detroit,  has  obtained  satisfactory  results  by  this  method. 

In  dermatological  practice  the  method  has  been  applied 
to  the  treatment  of  localized  staphylococcus  infections 
(acne,  sycosis,  furunculosis),  and  those  of  the  Bacillus 
tuberculosis  (lupus  and  other  cutaneous  tuberculoses). 


526         GENERAL  TREATMENT  AND  METHODS 


THE  MIXED  TOXINS  OF  ERYSIPELAS  AND  BACILLUS 
PRODIGIOSUS. 

Occasional  reports  of  improvement  in  malignant  growths 
after  accidental  infection  with  erysipelas  led  to  the  idea 
of  the  therapeutic  use  of  its  toxin.  The  introduction 
of  the  living  germ,  resorted  to  by  Coley  in  desperate 
cases  prior  to  1893,  was  a  dangerous  practice,  since  its 
later  multiplication  could  not  be  controlled,  whereas  the 
toxin  admits  of  exact  dosage.  Roger,  of  Paris,  having 
shown  that  the  Bacillus  prodigiosus  had  the  power  of 
making  the  streptococcus  of  erysipelas  more  virulent  to 
rabbits,  Dr.  William  B.  Coley,  of  New  York,  in  1892,  com- 
bined the  two  germs,  thus  securing  a  mixed  toxin  for 
hypodermic  use. 

The  manner  of  preparing  this  fluid  has  been  improved, 
from  time  to  time,  since  its  first  introduction.  Two  strengths 
are  now  advised  by  Dr.  Coley.  For  ordinary  cases,  the 
two  germs  are  grown  together  in  bouillon,  which  is  then 
sterilized  by  heating,  the  mixed,  unfiltered  toxins  (that  is, 
containing  the  dead  bacteria)  being  used.  For  children 
and  very  weak  persons,  the  mixed  living  cultures  are  passed 
through  a  porcelain  filter.  The  fluid  so  obtained  has  only 
from  one-fifteenth  to  one-tenth  the  strength  of  the  former. 

These  toxins,  by  their  presence,  bring  about  a  degenera- 
tion of  certain  malignant  cells.  According  to  Coley,  they 
are  successful  in  nearly  50  per  cent,  of  spindle-celled 
sarcomas  and  in  3  or  4  per  cent,  of  the  round-celled  form. 
In  carcinoma  the  method  has  wrought  very  few  cures,  and 
none  in  melanotic  sarcoma  or  lymphosarcoma.  Its  use 
should  be  restricted  to  two  classes  of  cases:  (1)  Inoperable 
growths ;  (2)  as  a  postoperative  treatment  to  destroy  pos- 
sible invisible  portions  left  behind,  and  thus  prevent  recur- 
rence. 

Injections  are  best  given  into  the  tumor  itself,  although 
distant  injections  also  yield  results.  One  should  always 
begin  with  a  minimum  dose,  \  to  \  minim  into  the  tumor, 


GALVANISM  527 

and  1  minim  at  a  distance,  gradually  increasing  until  a 
chill  occurs  followed  by  a  temperature  of  101°  to  104°  F. 
Daily  injections  are  better  when  they  can  be  borne.  Other- 
wise, injections  may  be  given  on  alternate  days.  If  soft 
and  fluctuating  areas  appear,  they  should  be  opened  and 
drained.  Tonics  should  be  given  during  the  treatment, 
and  careful  attention  be  given  to  keeping  the  bowels  free. 
Aseptic  precautions  are  especially  important,  since  the 
toxin  increases  susceptibility  to  pus  infection.  Reaction, 
both  local  and  general,  is  at  times  quite  sharp,  consisting 
of  erythema  beginning  at  the  puncture  and  extending  for 
several  inches  in  every  direction,  chill,  fever,  headache,  and 
vomiting.  At  other  times  but  little  immediate  effect  is 
noted.  Our  experience  substantiates  Dr.  Coley's  state- 
ment that  successful  cases  often  gain  weight  steadily  dur- 
ing treatment,  even  in  spite  of  marked  reactions.  If  no 
improvement  be  noticeable  within  four  weeks,  the  treat- 
ment should  be  abandoned.  As  long,  on  the  contrary, 
as  the  growth  continues  to  lessen,  injections  should  be 
continued.  Coley  secured  disappearance  of  an  inoperable 
carcinoma  after  two  and  one-half  years  of  bi-weekly  in- 
jections. 

GALVANISM. 

This  agent,  apart  from  its  use  in  electrolysis,  to  be  con- 
sidered under  a  separate  head,  has,  in  the  hands  of  most 
dermatologists,  been  employed  in  but  a  few  affections, 
although  a  list  of  all  those  in  which  it  has  been  essayed 
and  even  advocated  by  individuals  possessed  of  a  particu- 
lar predilection  for  electrotherapy,  would  include  a  large 
share  of  our  nosology.  References  to  its  special  employ- 
ment will  be  found  under  the  separate  heads  in  the  first  part 
of  this  work.  Its  chief  value,  hitherto,  has  been  to  control 
certain  subjective  symptoms,  such  as  dermatalgia,  pruritus, 
and  the  pains  accompanying  or  consecutive  to  zoster;  to 
increase  vascular  tone,  as  in  rosacea;  to  promote  con- 
traction of  the  muscular  elements  of  the  skin,  as  in  sluggish 


528    GENERAL  TREATMENT  AND  METHODS 

types  of  acne;  to  stimulate  local  metabolic  and  resorptive 
processes,  as  in  scleroderma,  and  for  cataphoresis.  It 
seems  probable,  however,  that  hereafter  it,  as  well  as 
faradism  and  franklinism,  will  be  largely  displaced  by 
the  use  of  high-frequency  currents. 

The  resistance  of  the  human  body  to  the  electric  current 
being  extraordinarily  high,  and  the  contacts  at  the  elec- 
trodes usually  imperfect,  a  high  electromotive  force  is 
demanded,  such  as  is  furnished  by  a  number  of  cells  united 
in  series.  The  high  internal  resistance  of  such  an  arrange- 
ment is  by  no  means  desirable,  as  some  seem  to  think,  but 
is  unavoidable.  The  ordinary  medical  cell  furnishes  about 
one  volt  when  fresh.  Portable  batteries  usually  contain 
twenty-four  or  thirty-two  such  cells.  The  old  dip  bat- 
teries, consisting  of  zinc  and  carbon  elements  and  a  per- 
manganate electrolyte  were  cumbersome,  troublesome, 
irregular  in  action,  and  unreliable.  Some  of  the  modern 
fluid  batteries  are  much  better,  but  far  superior  in  light- 
ness, portability,  and  general  convenience,  requiring  abso- 
lutely no  care;  and  always  ready  for  work  are  the 
dry-cell  batteries.  The  cells  when  exhausted  can  be 
replaced  at  small  cost.  Almost  the  only  way  in  which 
such  an  apparatus  can  be  damaged  is  by  short-circuiting, 
as  by  carelessly  laying  a  moist  sponge  electrode  on  the 
plugging-in  board.  One  should  avoid  using  certain  cells 
repeatedly  to  the  exclusion  of  others,  lest  these  become 
exhausted  and  thus  interrupt  the  circuit,  while  other  cells 
are  still  comparatively  fresh.  It  is  much  better  to  use  the 
entire  number  of  cells  at  each  sitting,  interposing  suffi- 
cient resistance  to  reduce  the  current  as  desired.  The 
life  of  the  battery  will  thereby  be  much  lengthened. 

The  importance  of  the  size  and  construction  of  the 
electrodes  is  apparent  when  we  remember  that  the  current 
is  equal  to  the  electromotive  force  divided  by  the  resist- 
ance, and  that  the  resistance  of  an  electrode  varies  inversely 
as  its  contact  area.  Besides,  the  larger  this  area,  the  less 
the  local  sensation  and  reaction.  To  procure  a  local  effect, 
therefore,  a  small  electrode  should  be  applied  to  the  area 


STATIC  ELECTRICITY  529 

to  be  influenced,  while  the  other  should  be  large.  For 
a  general  effect  both  electrodes  should  be  large.  They 
should  permit  of  close  application  to  the  surface.  Lead 
sheets  covered  with  wash-leather  make  excellent  non- 
active  electrodes. 

FARADISM. 

We  may  say  of  faradism,  as  of  galvanism  and  franklin- 
ism,  that  since  the  advent  of  the  high-frequency  current  its 
use  in  cutaneous  therapy  promises  to  be  even  more  re- 
stricted than  it  has  hitherto  been.  Of  the  three  modali- 
ties first  mentioned,  faradism  has  probably  been  the  least 
employed.  Stelwagon,  however,  believes  it  to  be  of  value 
in  acne,  using  an  ordinary  or  roller  electrode;  in  alopecia, 
with  a  special  metallic  comb  or  brush,  and  in  alopecia 
areata,  applied  with  a  tinsel  electrode.  References  to  its 
employment  in  certain  other  conditions  will  be  found  in  the 
first  part  of  this  work.  Faradic  currents,  as  well  as  galvanic 
and  sinusoidal,  have  been  used  in  electric  baths. 


STATIC  ELECTRICITY. 

This  agent  has  never  been  accorded  a  wide  application 
in  dermatological  practice,  and  it  now  seems  probable  that 
it  is  to  be  largely  ousted  even  from  its  restricted  field  by  the 
high-frequency  current.  Inasmuch  as  most  practitioners 
engaged  in  o>ray  work  use  the  coil,  they  will  naturally 
add  to  it  a  high-frequency  apparatus,  which  can  be  done 
at  small  cost.  The  smaller  number  who  employ  a  static 
machine  will  probably  continue  its  occasional  therapeutic 
use,  as  the  two  forms  of  electricity  yield  similar  results 
in  many  respects. 

Static  electricity  may  be  employed  either  generally  or 
locally. 

Brocq,  Shoemaker,  and  Stelwagon  are  the  chief  advo- 
cates of  its  general  tonic  and  alterative  action  in  cutaneous 
34 


530    GENERAL  TREATMENT  AND  METHODS 

disease  associated  with  lack  of  nervous  tone,  such  as 
urticaria,  pruritus,  prurigo,  and  certain  forms  of  eczema. 

Locally,  the  roller  electrode  is  applied  (over  the  clothing) 
in  conditions  of  disturbed  local  innervation,  and  the  spark 
in  alopecia  areata. 

The  chief  methods  of  application  are  as  follows : 

1.  The  Static  "Bath." — The  patient  is  placed  upon  an 
insulated  stool  connected  with  one  pole  of  the  machine 
while  the  other  pole  is  grounded.    If  the  stool  be  connected 
with  the  positive  pole  the  patient  is  charged  with  positive 
electricity,  which  gradually  leaks  off  into  the  surrounding 
air.    If  it  be  connected  with  the  negative  pole,  the  current 
is  naturally  inverse.    The  "bath"  may  thus  be  either  posi- 
tive or  negative.      It  is  usually  continued  for  from  ten 
minutes  to  one-half  hour. 

2.  The  Static  Breeze. — The  patient  being  placed  on  the 
stool,  the  operator  brings  an  electrode  terminating  in  one  or 
several  metallic  points  a  few  inches  from  the  surface  to  be 
treated.   The  stream  of  repelled  electrons  is  felt  as  a  breeze. 

3.  The    Effleuve. — This    is    produced    with    a     blunt, 
wooden  electrode  and  causes  a  mild,  stinging  sensation. 

4.  The  Douche. — The  patient,  being  seated  on  the  stool, 
receives  a  discharge  from  an  electrode  in  the  form  of  a 
crown  or  disk,  furnished  with  numerous  points,  which  is 
suspended  over  his  head. 

5.  The  Roller. — This  is  moved  along  over  the  patient's 
clothes,  and  occasions  a  sharp,  pricking  sensation. 

6.  The  Spark. — This  is  obtained  with  a  metallic  elec- 
trode terminating  in  a  ball,  and  causes  a  sharp,  evanescent, 
local  reaction,  characterized  by  spasmodic  contraction  of 
the  muscular  elements  of  the  skin. 

Friction  machines  have  long  been  abandoned.  Of  the 
influence  machines,  the  Wimshurst  and  its  modifications 
are  virtually  unknown  in  this  country,  where  the  Holtz  and 
Toepler-Holtz  are  used  to  the  exclusion  of  other  types. 
The  latter  has  the  advantage  of  being  self-charging,  while 
the  former  yields  a  steadier  and  less  painful  discharge, 
and  a  longer  spark. 


HIGH-FREQUENCY  CURRENTS  531 


HIGH-FREQUENCY  CURRENTS. 

A  "high-frequency"  current  is  one  characterized  by  its 
extremely  rapid  oscillations  in  opposite  directions,  perhaps 
as  many  as  100,000,000  per  second,  and  at  a  high  voltage. 
It  possesses  the  remarkable  property  of  communicating 
similar  oscillations  to  any  body  possessing  electrical  capac- 
ity which  may  be  brought  into  contact  with  it,  even  though 
in  "open  circuit,"  in  other  words,  even  though  contact  be 
established  at  only  one  point.  Let  us  briefly  review  the 
principles  concerned  in  its  production. 

When  contact  is  made  between  the  outer  and  inner  arma- 
tures of  a  charged  Leyden  jar,  they  are  discharged.  It  was 
supposed  that  this  discharge  consisted  of  a  simple  and 
immediate  passage  of  opposite  electricities  in  opposite 
directions,  until  1842,  when  Joseph  Henry  showed  that 
this  was  true  only  when  the  conductor  was  of  high  resist- 
ance. With  a  conductor  of  .low  resistance,  discharge  is 
completed  only  after  a  series  of  exceedingly  rapid  oscilla- 
tions or  surgings  to  and  fro,  each  surge  as  it  were  over- 
reaching itself,  so  that  the  higher  potential  exists  alternately 
on  the  inside  and  outside  of  the  jar,  but  in  gradually 
lessening  amount,  until  both  armatures  are  brought  to  the 
same  electric  level. 

This  fact  is  utilized  in  the  production  of  high-frequency 
currents.  The  discharge,  however,  occurs  between  the 
inner  armatures  of  two  jars  or  other  condensers.  In  order 
to  maintain  the  charges  at  their  original  potential,  the 
intern?!  armatures  of  the  condensers  are  connected  to  the 
secondary  terminals  of  an  induction  coil,  or  to  the  poles  of  a 
static  machine.  An  air  gap,  introduced  between  the  inner 
armatures  as  a  resistance,  permits  the  accumulation  of 
electromotive  force  in  the  condenser.  As  soon  as  the 
electromotive  force  has  accumulated  sufficiently  to  break 
down  the  resistance,  a  spark  crosses.  The  resistance  of  the 
gap  at  once  sinks  down  to  nearly  nil,  and  the  to-and-fro 
surgings  begin,  just  as  a  pendulum  will  swing  to  and  fro 


532    GENERAL  TREATMENT  AND  METHODS 

as  soon  as  released.  This  happens  in  the  latter  case 
because  the  medium,  air,  is  easily  displaced,  or,  in  other 
words,  of  low  resistance.  If  the  medium  were  of  high 
resistance,  such  as  a  thick  oil,  oscillation  would  be  checked, 
as  in  a  meter  that  is  "dead  beat."  So  with  a  condenser, 
oscillation  can  only  occur  with  a  conductor  of  low  resistance, 
such  as  comes  into  existence  with  the  passage  of  the  spark. 

The  current  so  created,  while  possessing  a  sufficiently 
rapid  period  of  oscillation,  is  too  weak  for  practical  use. 
In  order  to  increase  its  tension  and  the  consequent  electro- 
static effects  in  its  vicinity,  we  make  use  of  two  coils  of 
wire,  or  one  coil  divided  into  two  parts,  the  first  known  as 
the  solenoid,  vibrator,  or  exciter,  and  the  second  as  the 
resonator. 

In  order  to  understand  the  functions  of  these  devices, 
it  will  be  necessary  to  consider  some  of  the  properties 
of  high-frequency  currents.  Their  propagation  in  "open 
circuit"  was  mentioned  in  the  opening  paragraph  of  this 
article.  Another  important  phenomenon  is  that  of 
resonance.  The  term  is  borrowed  from  the  physics  of 
sound  production.  Vibrations  produced  in  one  body  may 
be  communicated  to  another,  such  as  a  sounding  board, 
and  the  sound  thus  amplified.  These  may  be  forced 
vibrations,  of  the  same  period  as  those  of  the  tuning  fork, 
violin -string,  or  other  exciting  body.  Besides  these,  however, 
the  sounding  board  possesses  a  period  of  vibration  of  its 
own  and  responds  more  readily  to  that  tone  than  to  any 
other.  Electrical  "resonance"  presents  a  close  parallel  to 
this.  In  any  two-way  current  the  curve  of  quantity  regu- 
larly rises  and  falls  above  and  below  the  zero  line.  Besides 
this  there  is  the  curve  of  potential  or  tension.  These  two  do 
not  necessarily  coincide.  Self-induction  in  the  circuit  tends 
to  make  the  wave  of  electromotive  force  lag  behind  that  of 
amperage,  while  increase  in  capacity  brings  it  ahead  of  the 
latter.  Careful  adjustment  of  self-induction  and  capacity 
brings  the  crests  of  the  two  waves  together.  When  this 
occurs  there  is  said  to  be  resonance.  This  manifests  itself 
at  certain  nodal  points  along  the  circuit,  so  that  it  is  neces- 


HIGH-FREQUENCY  CURRENTS  533 

sary  to  tap  the  circuit  at  the  proper  point,  in  order  to  obtain 
the  effect.  The  position  of  such  a  node  in  a  resonator  can 
be  determined  by  experimentation.  At  a  point  midway 
between  two  nodes  the  effect  would  be  nil,  with  increase  in 
either  direction. 

The  period  of  oscillation  of  a  circuit  depends  upon  its 
capacity,  self-induction,  and  resistance. 

If  the  resonator  be  "tuned"  to  the  solenoid,  the  resulting 
interaction  between  syntonic  circuits  will  greatly  increase 
the  energy  of  the  current. 

The  quantity  of  current  will  depend  upon  the  energy  in 
the  primary  coil,  the  spark  length  between  the  internal 
armatures,  and  the  self-induction  of  the  solenoid  and 
resonator. 

In  the  d'Arsonval  resonator  a  few  turns  of  heavy  wire 
surround  an  ebonite  cylinder  at  a  distance  of  a  few  inches. 
Upon  the  cylinder  are  wound  many  turns  of  fine  wire.  A 
current  at  a  greatly  increased  tension  is  thus  induced  in  the 
latter.  Oudin's  inductoresonator  consists  of  thirty  or  forty 
turns  of  wire.  Several  turns  at  the  bottom  are  led  into 
a  circuit  between  the  armatures,  and  thus  serve  as  the 
solenoid.  The  other  turns  form  the  resonator. 

The  connection  between  the  resonator  and  patient  may 
be  direct  or  indirect,  and  is  made  in  various  ways.  The 
use  of  the  high-frequency  current  in  dermatology,  how- 
ever, is  virtually  limited  to  the  effleuve  from  an  electrode 
connected  with  a  single  or  "open-circuit"  wire  led  off 
from  the  end  or  top  of  the  resonator.  One  of  the  most 
astonishing  physiological  properties  of  these  currents  is 
that  they  produce  no  sensation  nor  muscular  contraction. 
Under  proper  conditions,  a  current  can  be  passed  through 
the  body  capable  of  lighting  125  lamps  of  1  ampere  each, 
each  mounted  in  series,  without  causing  discomfort.  In 
order  to  accomplish  this  negative  result,  the  oscillations  must 
be  extremely  rapid.  It  is  well  known  that  muscular  contrac- 
tions due  to  electric  (or  other)  stimuli  become  fused,  when 
the  latter  are  rapidly  repeated,  into  a  continuous  or 
"tetanic"  contraction.  As  the  rapidity  of  stimulation  is 


534    GENERAL  TREATMENT  AND  METHODS 

increased,  the  tetanic  response  at  first  rises;  then,  as  the 
stimuli  increase  from  2500  to  5000  per  second,  remains  at 
the  same  level,  and  with  a  further  increase  begins  again  to 
decline.  As  the  rate  of  oscillation  rises  still  higher,  all  con- 
traction is  finally  abolished.  The  most  plausible  of  the 
theories  invoked  to  account  for  this  absence  of  reaction  is 
that  duration  of  flux  in  one  direction  is  not  sufficient  to 
overcome  tissue  resistance  and  awake  a  response.  The 
current  energy  is  consumed  in  exciting  the  molecular 
disturbances  which  characterize  the  latent  stage  of  a  con- 
traction. This  theory,  thus,  at  the  same  time,  explains 
the  increased  metabolism  attendant  upon  the  presence  of 
currents  of  high  frequency.  These  currents  also  exert 
nervous  and  muscular  inhibitory  effects  which  may  account 
for  the  observed  anesthesia,  muscular  relaxation  (dimin- 
ished excitability),  and  vasodilatation  with  consequent  fall 
of  blood  pressure.  Effluvation  causes  tactile,  thermal, 
and  superficial  pain-sense  anesthesia,  soon  replaced  by 
hyperesthesia.  There  is  vasoconstriction,  soon  followed 
by  vasodilatation,  when  the  electrode  is  held  at  a  little 
distance  from  the  skin.  Vasoconstriction  does  not  occur 
when  the  electrode  is  in  contact  with  the  surface. 

High-frequency  currents  have  been  found  of  service 
chiefly  in  pruritic  affections,  such  as  pruritus,  especially 
the  local  forms,  prurigo,  urticaria,  etc.,  and  in  such  circu- 
latory disturbances  as  lupus  erythematosus,  rosacea,  and 
some  eczemas.  Allen  mentions  acne,  molluscum  contagio- 
sum,  sycosis,  impetigo,  lupus,  common  and  venereal  warts, 
keloid,  atrophy  of  skin,  alopecia  areata,  pityriasis  versi- 
color,  and  pigmentations.  He  employs  "  sparking"  from  a 
pointed  metallic  electrode  for  destruction  of  small  tumors, 
vascular  and  other  nevi,  epithelioma,  lupus,  etc.,  protect- 
ing the  surface  with  a  sheet  of  vulcanite  presenting  an 
aperture  just  large  enough  to  expose  the  lesion.  We  have 
obtained  excellent  results  with  this  agent  in  general  deflu- 
vium  capillorum  in  women,  uncomplicated  with  seborrhea. 

Special  indications  for  the  use  of  these  currents  will  be 
found  under  the  different  diseases. 


ELECTROLYSIS  535 


ELECTROLYSIS. 

The  principle  of  electrolysis  is  illustrated  by  the  familiar 
experiment  of  plunging  two  platinum  wires  into  acidulated 
water  a  little  distance  apart,  one  wire  being  connected  with 
the  positive  pole  of  a  galvanic  battery,  and  the  other  with 
the  negative.  As  soon  as  the  current  passes,  decomposi- 
tion of  the  water  into  its  component  gases  begins,  the 
electropositive  element,  hydrogen,  being  liberated  at  the 
negative  electrode,  while  the  electronegative  element, 
oxygen,  appears  at  the  positive  wire.  The  gases  may  be 
collected  for  testing  over  their  respective  electrodes.  It  is 
at  first  sight  a  little  puzzling  that  only  one  gas  should  appear 
at  each  pole,  since  each  molecule  of  water  contains  both. 
This  phenomenon  is  accounted  for  by  an  exchange  of 
elements  along  a  chain  of  molecules  from  one  electrode  to 
the  other.  We  may,  if  we  choose,  mentally  picture  the 
hydrogen  in  each  molecule  as  combining  with  the  oxygen 
in  the  one  next  adjacent  in  the  direction  of  the  negative 
electrode,  thus  forming  a  new  set  of  molecules  and  leaving 
over  an  atom  of  hydrogen  to  be  liberated  at  the  end  of  the 
chain,  while  the  same  thing  is  occurring  with  respect  to 
oxygen  in  the  opposite  direction. 

Therapeutically,  we  produce  the  same  effect  on  the 
watery  element  of  the  blood  and  tissues.  In  bipolar  elec- 
trolysis two  needles  are  plunged  into  the  tissue  to  be  acted 
upon — one  connected  with  each  pole  of  the  battery.  The 
method  is  not  wholly  satisfactory,  inasmuch  as  there  is  a 
wide  difference  between  the  reaction  obtained  at  the  two 
needles.  The  oxygen  at  the  positive  electrode  determines 
a  coagulation  of  albumins,  giving  a  relatively  dry  eschar 
and  causing  the  tissues  to  adhere  to  the  needle,  while  at  the 
negative  electrode,  in  default  of  coagulation,  the  little  mass 
of  destroyed  tissue  is  less  contracted  and  moister,  allowing 
easy  withdrawal  of  the  needle. 

Unipolar  electrolysis,  employing  the  negative  needle,  is 
the  method  of  choice  in  dermatological  practice.  The 


536    GENERAL  TREATMENT  AND  METHODS 

technique  is  set  forth  in  full  in  the  article  on  Hypertrichosis. 
For  the  destruction  of  varicose  vessels,  in  the  second  stage 
of  rosacea,  a  fine  needle  is  passed  into  the  venule.  When 
the  current  is  made,  close  observation  will  detect  minute 
bubbles  of  hydrogen  coursing  along  the  dilated  vessel,  soon 
after  which  the  little  vascular  twig  momentarily  appears 
outlined  by  its  pallor.  For  the  destruction  of  warts,  small 
epitheliomata,  and  other  small  lesions,  a  number  of  parallel 
through-and-through  punctures  are  made  across  the  base 
of  the  growth,  intersected  by  a  second  series  at  right  angles 
to  the  first,  thus  forming,  as  it  were,  a  floor  of  necrosis  which 
shuts  off  the  nutrition  of  the  tissues  above  its  level.  In 
dealing  with  flat  pigmentory  nevi  the  finest  needle  obtain- 
able should  be  passed  in  horizontally  at  the  level  of  the 
papillary  body,  as  many  punctures  being  made  as  necessary. 
The  indications  for  the  use  of  electrolysis,  in  the  various 
affections,  can  be  found  in  the  first  part  of  this  work. 

CATAPHORESIS. 

Cataphoresis  is  the  power  of  the  galvanic  current  to 
induce  osmosis  from  the  positive  to  the  negative  pole 
(Billings).  It  is,  therefore,  also  called  electrical  osmosis. 

In  medical  parlance  the  term  means :  (1 )  The  introduc- 
ing of  drugs  through  the  unbroken  skin  by  means  of  gal- 
vanism. Its  feasibility  is  proved  by  the  finding  of  the 
substance  in  the  urine  or  saliva.  Experiments  in  this 
direction  were  made  as  long  ago  as  1747,  and  taken  up 
with  renewed  ardor  about  one  hundred  years  later.  (2) 
Introduction  through  an  ulcerated  surface.  (3)  The  simul- 
taneous employment  of  cataphoresis,  properly  so  called, 
with  electrolysis.  A  metallic  disk  is  applied  to  an  ulcerated 
surface,  or  a  needle  thrust  into  the  tissues.  A  soluble  salt 
of  the  metal  being  formed  by  electrolysis,  acts  in  part  as  a 
cauterant  on  surfaces  in  immediate  contact,  and  is  in  part 
carried  from  the  positive  pole  into  more  distant  tissues  by 
cataphoresis,  there  exerting  an  antiseptic  or  other  remedial 
effect. 


CATAPHORESIS  537 

While,  as  already  implied,  drugs  may  by  this  means  be 
introduced  into  the  circulation,  the  method  is  virtually 
restricted  to  driving  them  into  the  tissues  adjacent  to  the 
positive  electrode.  Its  chief  applications  to  cutaneous 
therapy  are  here  mentioned: 

1.  Cataphoresis  through  the  unbroken  skin. 

This  method  was  advocated  some  twenty  years  ago  in 
vegetable  parasitic  diseases  of  the  hair,  as  a  means  of  over- 
coming the  difficulties  of  medication  incident  to  the  inac- 
cessible situation  of  the  fungus.  Whatever  importance  it 
may  have  acquired  has  been  much  lessened  by  the  advent 
of  the  x-rays  as  an  epilating  agent. 

The  introduction  of  cocaine  and  other  local  analgesics  by 
cataphoresis  through  the  skin  has  been  less  successful  than 
that  by  way  of  the  mucous  membranes.  In  the  former  case 
the  surface  should  be  well  cleansed  of  fat  by  soap  and 
water  followed  by  ether. 

A  flat,  metal  electrode  is  covered  with  several  layers  of 
plain  gauze  soaked  in  a  solution  of  the  drug  to  be  used.  In 
the  case  of  cocaine  this  must  not  be  less  than  10  per  cent. 
This  electrode,  connected  with  the  positive  pole  of  a 
battery,  is  placed  over  the  surface  to  be  treated,  and  the 
negative  electrode  at  any  indifferent  point.  Eight  to 
30  volts  may  be  used.  The  resistance  of  the  horny  layer 
being  enormous,  the  current  is  at  first  but  a  few  milli- 
amperes.  Soon,  however,  it  begins  to  rise,  owing  to  the 
epidermis  under  the  positive  electrode  becoming  a  better 
conductor  as  the  solution  permeates  it.  The  current  may 
be  continued  for  ten  to  fifteen  minutes. 

2.  Cataphoresis  through  an  ulcerated    surface  has  been 
recently  advocated  in  superficial  epithelioma,  q.  v. 

3.  Cataphoresis      used     concurrently    with     electrolysis. 
Gautier  treated  actinomycosis,  lupus,  and  sycosis  by  intro- 
ducing a  copper  needle  connected  to  the  positive  pole,  thus 
obtaining  an  oxychloride  of  copper.    In  the  condition  first 
named  he  also  used  the  plan  of  first  injecting  a  solution  of 
potassium  iodide.     Edwards  uses   zinc  or  zinc-mercury 
disks  in  superficial  epithelioma,  q.  v. 


538         GENERAL  TREATMENT  AND  METHODS 

Morton,  of  New  York,  and  Massey,  of  Philadelphia 
employed  cataphoresis  in  inoperable  cancer.  J.  McFadden 
Gaston  successfully  treated  a  small,  round-celled  sarcoma 
in  this  way. 

THE  X-RAYS. 

Introduction. — It  was  in  1895  that  Rontgen,  studying 
the  phenomena  incident  to  the  passage  of  an  electric  dis- 
charge through  a  Crookes  tube,  found  a  form  of  radiant 
energy  which,  although  invisible,  could  affect  the  photo- 
graphic plate,  and  possessed  the  remarkable  property  of 
passing  through  many  bodies  opaque  to  light. 

Rontgen  became  aware  of  the  existence  of  these  rays  by 
the  fact  that  some  crystals  of  barium  platinocyanide  which 
were  lying  near  by  became  luminous.  This  led  him  to 
construct  a  screen  covered  with  a  layer  of  this  substance,  to 
which  was  given  the  name  of  fluoroscope. 

A  full  exposition  of  the  nature  of  these  phenomen 
would  be  foreign  to  the  scope  of  this  work.    It  may  be  well, 
however,  to  give  a  succinct  account  of  the  physical  facts  on 
which  they  rest. 

It  is  well  known  that  when  two  terminals,  the  one  con- 
nected with  the  positive  end  of  a  source  of  electric  energy 
and  the  other  with  the  negative,  are  brought  sufficiently 
near  to  each  other,  there  occur  certain  modifications  of 
the  intervening  air  space.  According  to  present  ideas,  the 
atoms  are  broken  up  into  their  constituent  ions  or  electrons, 
that  is,  into  units,  some  charged  with  (or  consisting  of) 
positive  electricity  and  some  negative. 

If  the  voltage  be  sufficient,  that  is,  if  the  electric  pressure 
be  sufficiently  high  to  overcome  the  resistance,  there  will 
be  incandescence  of  the  air  along  the  path  of  discharge, 
with  sudden  rarefaction,  the  collision  between  air  surfaces 
rushing  back  to  occupy  the  spaces  from  which  they  have 
just  been  displaced  occasioning  a  sharp  report.  In  other 
words,  there  is  sparking. 

Let  the  terminals  be  enclosed  within  a  glass  shell  con- 


THE  X-RAYS  539 

nected  with  an  exhaust  apparatus.  As  the  atmosphere  is 
progressively  rarefied  we  may  observe  the  phenomena 
attending  the  passage  of  the  current. 

At  first  the  line  of  sparks  widens  out  into  luminous 
plumes,  continuous  from  one  terminal  to  the  other.  The 
number  of  molecules  of  gas  within  the  shell  being  still 
further  reduced,  and  the  resistance  correspondingly  in- 
creased, the  luminous  plumes  change  to  an  uninter- 
rupted glow  surrounding  each  terminal,  with  a  dark  space 
between. 

Let  us  now  employ  Crookes'  original  tube,  the  negative 
terminal  or  cathode  being  at  one  end  of  the  tube  and  the 
positive  or  anode  introduced  at  one  side.  With  a  further 
degree  of  rarefaction  a  dark  space  appears,  bounded  on  one 
side  by  the  cathode  and  on  the  other  by  a  luminous  zone. 
Air  pressure  being  further  reduced,  the  width  of  the  dark 
zone  increases  until  it  extends  to  the  opposite  wall  of  the 
tube,  which  now  becomes  luminous.  With  the  highest 
vacuum  obtainable,  resistance  becomes  so  great  that  there 
is  no  further  passage  of  electricity,  and  a  consequent 
cessation  of  visible  manifestations. 

Crookes'  explanation  of  these  phenomena  is  substantially 
as  follows :  The  terminals  being  electrified,  the  atoms  of  gas 
are  dissociated  into  their  component  electrons.  The  nega- 
tive electrons,  each  believed  to  possess  a  mass  equal  to  about 
Yinro  of  an  atom  of  hydrogen,  which  are  in  contact  with,  or 
near,  the  cathode,  are  violently  driven  off,  in  accordance 
with  the  well-known  law,  that,  whereas  bodies  possessing 
opposite  electrifications  are  attracted  to  each  other,  those 
similarly  charged  are  repelled.  In  a  low  vacuum,  the 
electrons,  before  they  have  travelled  any  distance,  come  into 
violent  collision  with  other  electrons,  as  in  the  case  of  a 
person  attempting  to  cross  a  ball-room  crowded  with 
dancers.  These  collisions,  by  the  heat  so  generated, 
occasion  the  luminous  glow  about  the  terminals.  Now  as 
the  vacuum  becomes  higher,  the  electrons  are  allowed  to 
make  a  longer  rush  before  being  "  tackled,"  and  thus  occurs 
the  dark  space  about  the  cathode  which  widens  as  the 


540        GENERAL  TREATMENT  AND  METHODS 

electrons  in  their  path  become  fewer  and,  therefore,  the 
chances  of  collisions  grow  less.  Finally,  the  total  number 
of  electrons  within  the  tube  is  so  reduced  that  they  pursue 
parallel  paths  without  interruption,  until  stopped  by  the 
opposite  glass  wall,  which  begins  to  fluoresce  under  their 
bombardment.  This  flight  of  negative  electrons  across 
the  tube  (at  a  rate  estimated  by  Crookes  at  15,000  miles 
a  second,  or  about  ^  that  of  light;  J.  J.  Thomson  and 
Lenard  call  it  about  -j^)  is  known  as  the  Cathode  Ray.  If 
this  theory  be  correct,  it  is  an  instance  of  electric  con- 
vection. Wiedemann,  on  the  other  hand,  holds  to  the 
hypothesis  that  the  cathode  ray  consists  of  very  short 
ether  waves. 

Whatever  theory  we  adopt,  the  facts  are  that  this  ray 
travels  in  a  direction  perpendicular  to  the  plane  of  the 
cathode  (irrespective  of  the  position  of  the  anode),  that  it 
carries  a  negative  charge,  that  it  can  be  deflected  by  a 
magnet,  and  that  it  causes  fluorescence  of  the  opposite  wall 
of  the  tube.  At  the  points  of  impact  of  the  cathode  rays 
with  the  glass,  there  originate  Rontgen  rays,  or,  as 
Rontgen  named  them,  x-rays,  expressing  thereby  the  fact 
that  their  nature  was  unknown.  These  penetrate  many 
media  impermeable  to  light,  the  opacity  of  media  to  the  rays 
varying  in  a  general  way  as  their  density;  they  travel  in 
straight  lines  in  all  directions  from  their  points  of  origin; 
cannot  be  reflected,  refracted,  diffracted  nor  polarized,  and 
show  no  interference  phenomena,  that  is,  they  exhibit  along 
their  course  no  points  of  increased  or  diminished  intensity 
such  as  arise  from  the  superposition  of  waves  of  different 
phase.  These  negative  characteristics  are  perhaps  due  to 
their  extremely  short  wave  length  (according  to  Haya  and 
Wind  only  y^Vfr  the  length  of  a  wave  of  green  light). 
They  affect  the  photographic  plate  and  excite  fluorescence 
in  certain  chemical  substances.  They  are  not  affected  by  a 
magnetic  or  electric  field,  but  rapidly  discharge  all  near-by 
electrified  bodies.  This  they  do  by  ionizing  the  air,  that  is, 
by  making  it  a  conductor.  The  air  retains  its  conductivity 
for  awhile  even  after  it  is  blown  out  of  the  path  of  the  rays. 


THE  X-RAYS  541 

While,  as  just  stated,  x-rays  are  not  reflected,  yet  they 
possess  a  property  which  yields  results  in  some  particulars 
like  those  of  reflection,  namely,  that  solid  matter  on  which 
they  impinge  emits  secondary  x-rays,  which  may  in  turn 
excite  tertiary  rays.  These  are  less  penetrating  than  the 
original  rays.  A  practical  deduction  from  this  fact  is  the 
presence  of  rays  virtually  in  all  directions  about  an  active 
tube. 

The  velocity  of  the  rays,  according  to  Blondlot,  is  the 
same  as  that  of  Hertz  waves  or  of  light.  This  all  but 
proves  that  the  x-rays  are  disturbances  of  the  ether  and  not 
a  flight  of  material  particles  such  as  is  the  cathode  rays. 

The  year  following  Rontgen's  discovery,  Jackson  im- 
proved the  tube  by  inserting  a  platinum  disk  at  an  ob- 
lique angle  to  the  path  of  the  cathode  rays.  This  being 
connected  to  the  anode  by  a  wire  outside  the  tube,  is  itself 
really  an  anode,  but  is  known  as  the  anticathode  or  target. 
In  this  form  of  tube  the  x-rays  originate  at  the  anticathode 
and  spread  over  that  half  of  the  tube  which  it  faces.  In 
some  tubes  there  are  but  two  terminal  points,  the  anode 
terminating  in  a  disk  set  at  an  oblique  angle  to  the  path  of 
the  cathode  ra^s,  and  thus  itself  serving  as  an  anticathode. 
The  cathode  terminal  is  concave,  the  centre  of  its  curva- 
ture, in  a  good  tube,  coinciding  with  the  centre  of  the 
anode.  The  plane  of  the  latter  should  be  at  an  angle 
of  45  degrees  to  the  axis  of  the  tube. 

With  radioscopy  and  radiography  we  are  here  not  con- 
cerned. The  use  of  the  rays  for  these  purposes,  however, 
occasionally  caused  painful  and  sometimes  serious  inflam- 
mation and  destruction  of  tissues  within  exposed  areas  of 
patients  and  of  the  operator's  hands.  This,  in  1896, 
suggested  to  Schiff  and  Freund  the  idea  of  employing  this 
reaction  as  a  therapeutic  agent. 

Installation. — In  order  to  obtain  x-rays  we  require  a 
Crookes  tube  and  a  source  of  electrical  energy  at  high 
pressure,  but  of  comparatively  small  volume. 

For  the  latter  purpose  we  may  use  the  static  machine 
or  an  induction  coil. 


542    GENERAL  TREATMENT  AND  METHODS 

The  Static  Machine. — There  are  two  types  of  this  device, 
the  friction  machine  and  the  influence  machine.  The  latter 
only  is  used  in  the  production  of  x-rays.  In  order  to  secure 
high  voltage  a  number  of  disks  or  plates  are  used.  These 
should  be  made  of  material  possessing  a  high  dielectric 
coefficient;  glass,  mica,  or  ebonite  being  used.  The  power 
to  revolve  the  plates  may  be  furnished  by  an  electric  or 
other  motor,  or  by  hand. 

Good  machines  furnished  with  16  stationary  and  16 
revolving  plates  will  furnish  a  small  volume  of  electricity, 
perhaps  as  low  as  5  ma.,  at  from  100,000  to  500,000 
volts,  giving  with  a  proper  tube  a  clear  and  steady  light 
with  distinctly  outlined  hemisphere.  The  discharge  is 
much  weaker  than  that  from  a  coil,  but  on  the  other  hand 
occupies  the  whole  period  with  an  even  flow.  The  advan- 
tages claimed  for  the  static  machine  are,  first,  that  it  fur- 
nishes a  one-way  current,  that  is,  there  is  no  reverse  surge 
due  to  changes  of  polarity,  as  with  the  coil,  and  thus  the 
life  of  the  tube  is  increased;  and,  in  the  second  place,  that 
there  is  no  necessity  for  an  interrupter,  confessedly  the 
most  troublesome  part  of  a  coil  outfit.  Besides,  it  permits 
the  use  of  much  lighter  and,  therefore,  cheaper  tubes. 
The  objections  urged  against  the  static  machine  by  Euro- 
pean writers,  that  they  easily  get  out  of  order,  that  they 
require  constant  care  such  as  daily  wiping  of  the  plates  and 
frequent  washing  in  alcohol,  etc.,  do  not  apply  to  the 
greatly  superior  American  machines,  which  only  require 
keeping  a  little  common  lime  in  the  case  as  a  drier,  to  be 
changed,  perhaps,  once  in  two  weeks  in  the  summer,  and 
once  in  the  course  of  the  winter,  varying  a  little  from  this 
according  to  humidity.  Experienced  operators  maintain 
one  or,  better,  several  spark-gaps  on  the  negative  side. 

A  peculiarity  of  the  static  machine  is  that  its  output 
increases  with  the  resistance.  Therefore,  with  it  a  hard 
tube  will  give  not  only  more  penetrating  rays,  but  a  greater 
number  of  rays,  both  hard  and  soft.  This  is  why  certain 
observers,  working  with  a  static  machine,  have  reported 
a  more  rapid  effect  from  a  hard  than  from  a  soft  tube. 


THE  X-RAYS  543 

An  influence  machine,  such  as  the  Holtz,  or  Toepler- 
Holtz,  of  sufficient  voltage,  will  give  very  satisfactory 
results  in  the  hands  of  one  accustomed  to  its  use.  In  the 
country  or  in  small  towns  not  furnished  with  a  public 
supply,  such  a  machine  is  the  only  available  source  of 
energy. 

The  contention  that  burns  caused  by  a  static  machine  are 
less  severe  than  those  from  a  coil  is  not  in  accord  with 
observed  facts. 

The  Induction  Coil. — A  description  of  the  construction  of 
the  coil  or  an  exposition  of  the  laws  involved  in  its  operation 
would  be  here  out  of  place.  The  proportion  between  the 
calibres  of  the  primary  and  secondary  wires  and  the  num- 
ber of  windings  of  each  can  only  be  determined  when  the 
voltage  and  amperage  of  the  supply  energizing  the  coil  and 
the  desired  output  of  the  secondary,  or  in  other  words  the 
kind  of  work  to  be  done,  are  known.  A  reliable  maker, 
on  being  given  the  particulars  as  to  the  available  supply  of 
power,  will,  if  the  latter  be  sufficient,  furnish  a  coil  wound  so 
as  to  yield  the  necessary  current  for  therapeusis,  or  for 
light  or  heavy  radiographic  work.  There  are  a  number  of 
excellent  coils,  expressly  designed  for  the  production  of  the 
x-rays,  now  upon  the  American  market. 

Inasmuch  as  all  cutaneous  therapy  is  best  done  with  an 
equivalent  spark  of  less  than  six  inches,  and  most  of  it  with 
less  than  half  that,  it  might  seem  a  useless  extravagance  to 
buy  a  coil  capable  of  furnishing  a  spark  of  twelve  inches 
or  more.  So,  indeed  it  is,  if  one  believes,  with  Pusey,  in 
limiting  one's  self  to  the  use  of  currents  of  low  intensity. 
For  obtaining  a  larger  volume,  however,  one  needs  a  coil 
capable  of  yielding  a  spark  twice  as  long  as  will  ever  be 
used,  as  only  then  will  the  shorter  spark-lengths  be  accom- 
panied by  any  considerable  amount  of  energy. 

The  Condenser. — The  better  coils  are  furnished  with 
condensers  of  which  the  capacity  may  be  varied  at  will. 
Practically,  however,  the  operator  soon  learns  what  con- 
denser capacity  gives  the  best  result  and  finds  no  occasion 
to  change  it  thereafter.  The  condenser  takes  up  the  extra 


544    GENERAL  TREATMENT  AND  METHODS 

direct  current  produced  in  the  primary  by  the  break.  This 
extra  current,  rebounding,  is  led  back  through  the  primary 
in  the  opposite  direction,  thus  opposing  the  direct  current 
and  rapidly  demagnetizing  the  core.  As  the  electromotive 
force  in  the  secondary  depends  upon  the  rapidity  with 
which  the  lines  of  force  disappear,  it  is  much  increased  by 
the  use  of  the  condenser.  Besides,  were  not  the  extra  direct 
current  thus  taken  care  of,  it  would  produce  heavy  and 
injurious  sparking  at  the  break  in  the  interrupter.  This 
is  easily  demonstrated  in  any  coil  operated  through  a 
mechanical  interrupter  by  switching  out  the  condenser. 
With  electrolytic  interrupters  no  condenser  is  used,  as  the 
extra  current  is  itself  the  electrolytic  agent  (see  p.  549). 

Inductance. — Large  coils  are  generally  made  with  a 
primary  of  variable  inductance  (formerly  spoken  of  as  the 
coefficient  of  self-induction),  that  is,  that  factor  which 
multiplied  by  the  current  strength  determines  the  amount 
of  self-induction.  The  primary  is  wound  in  two  or  more 
sections  which  may  be  connected  up  either  in  series  or  in 
parallel.  With  the  former  arrangement,  self-induction  is 
greater,  the  break  less  sharp,  and  the  output  between  the 
secondary  terminals,  as  shown  by  the  spark-length,  con- 
siderably less.  This  is  best  suited  to  soft  tubes.  WTith 
hard  tubes  the  sections  connected  in  parallel  give  better 
results.  We  are  thus  furnished  with  another  method  of 
controlling  the  amount  of  energy  supplied  by  the  coil,  an 
intelligent  use  of  which  will  add  materially  to  the  life  of  the 
tube.  In  American  machines  this  arrangement  is  controlled 
by  a  switch  instead  of  the  cumbersome  devices  of  the 
German  coils. 

Spark-gaps. — Coils  are  furnished  with  adjustable  series 
and  parallel  spark-gaps.  The  former,  which  may  be  one 
or  several  at  each  pole,  serve  to  insert  resistances  into  the 
secondary  circuit,  and  thus  help  to  eliminate  that  second- 
ary current  which  accompanies  the  make  or  closure  of  the 
primary  circuit.  This  current  is  at  a  far  lower  voltage  than 
the  break  current,  although  the  amperage  is  the  same.  The 
secondary  current  is  by  this  device  made  unidirectional, 


THE  X-RAYS  545 

eliminating  the  reverse  surge  through  the  tube,  and  thus 
preserving  it  from  injury.  The  resistance  within  the  tube 
itself,  however,  generally  accomplishes  this,  at  least  in 
great  part.  The  valve  tube  to  be  inserted  into  the  sec- 
ondary circuit  is  designed  for  the  same  end.  While  doubt- 
less efficient,  it  may  usually  be  dispensed  with,  the  series 
gaps  answering  the  purpose  desired.  Of  course,  without 
some  such  arrangement  an  induction  coil  could  not  be 
said  to  have  an  anode  and  a  cathode,  inasmuch  as  these  are 
constantly  being  reversed.  With  it,  however,  we  can  neglect 
the  polarity  originated  by  the  make. 

The  parallel  gap  is  so  disposed  as  to  offer  a  "shunt" 
circuit  or  alternative  path  for  the  secondary  current. 
Electricity,  like  everything  else,  following  the  line  of  least 
resistance,  will  either  pass  through  the  conducting  wires  and 
tube,  or  leap  the  parallel  gap,  accordingly  as  one  or  the 
other  offers  the  easier  path.  The  length  of  the  gap,  there- 
fore becomes  a  measure  of  resistance  within  the  tube, 
and  when  used  for  that  purpose  is  called  a  spintenneter. 
When  we  speak  of  a  "6-in."  or  a  "15-cm."  tube,  we, 
therefore,  mean  one  possessing  a  vacuum  of  such  resist- 
ance as  can  only  be  overcome  by  a  current  capable  of 
sparking  in  the  air  across  a  gap  of  that  length. 

A  voltmeter  and  ammeter  in  the  primary  circuit  are 
useful  as  indicating  in  a  general  way  the  amount  of  energy 
being  expended.  We  must  remember,  however,  that  the 
current  actually  passing  through  the  tube  is  probably  at 
several  thousand  times  the  voltage,  and  only  at  the  several 
thousandth  part  of  the  amperage  of  that  of  the  primary. 
Many  successful  American  operators  dispense  with  meters 
altogether  and  derive  sufficient  guidance  from  the  degree 
of  illumination  of  the  tube. 

Sources  of  Energy. — The  coil  may  be  energized  from 
various  sources.  The  current  entering  the  primary  must  be 
unidirectional  and  intermittent.  In  cities  where  a  direct 
current  is  supplied,  this  may  be  led  immediately  into  the 
machine  by  introducing  sufficient  resistance  to  lower  it 
to  the  potential  suited  to  the  particular  installation.  Where 
35 


546         GENERAL  TREATMENT  AND  METHODS 

only  an  alternating  current  can  be  had,  this  may  be  used  to 
operate  a  motor  to  which  is  then  geared  a  dynamo  furnish- 
ing a  direct  current  of  the  desired  voltage  and  amperage. 

There  exist  other  methods  for  converting  an  alternating 
into  a  one-way  current.  One  of  these  is  the  electric  valve, 
in  which  one  electrode  is  made  of  aluminum  and  the  other 
of  some  other  metal.  A  thin  coating  of  oxide  interferes 
with  the  passage  of  the  current  when  the  aluminum  is  the 
anode,  but  allows  it  to  pass  freely  in  the  opposite  direction. 
This  conversion  is  also  effected  by  several  types  of  inter- 
rupters, as  described  below.  A  storage  battery  may  be 
used  when  a  supply  current  for  storing  is  available.  The 
latter  arrangement  is,  perhaps,  the  most  practicable  one  for 
operating  the  smaller  portable  coils,  giving,  say,  up  to  an 
eight-inch  spark,  although  a  public  direct-current  supply  may 
be  utilized  by  introducing  sufficient  resistance.  Galvanic 
batteries  are  ill-suited  to  the  purpose. 

The  Rheostat. — A  rheostat  is  introduced  into  the  primary 
circuit,  by  which  the  strength  of  the  inducing  current  may 
be  varied,  thus  permitting  us  to  affect  the  induced  current 
through  the  tube. 

The  Interrupter. — Perhaps  no  part  of  the  installation  will 
require  as  much  thought  or  elicit  such  a  variety  of  opinion 
as  the  choice  of  an  interrupter.  Here  again,  the  operator 
wishing  to  employ  his  equipment  in  diagnosis  will  obtain 
the  best  results  with  an  electrolytic  interrupter  capable  of 
accommodating  a  large  voltage,  or  with  a  mechanical 
device  of  the  revolving  type  such  as  the  Contremoulin, 
giving  the  sharpest  break,  and  supplied  with  a  device  for 
altering  the  positions  of  the  collecting  brushes,  allowing 
the  operator  to  modify  the  cycle  so  as  to  increase  the  time 
occupied  in  the  passage  of  the  current  at  the  expense  of 
the  pause,  thus  increasing  the  maximum  current  in  the 
primary.  One  may  thus  dispense  with  a  rheostat.  For 
treatment,  instruments  affording  sixty  breaks  per  second 
or  even  less  will  be  sufficient. 

Smaller  coils  are  often  provided  with  a  modification  of  the 
Neef  hammer,  such  as  the  independent  vibrator.  Here  the 


THE  X-RAYS  547 

vibrator,  which  is  attracted  by  the  magnetized  core,  does 
not  itself  break  the  contact,  but  at  a  point  in  its  excursion, 
when  it  has  acquired  a  high  rate  of  speed,  strikes  upon 
another  spring  through  which  the  current  passes,  and 
pushes  it  away  from  its  contact,  thus  affording  a  sharper 
break.  While  this  is  a  great  improvement  on  the  original 
vibrator,  there  is  still  some  cling  at  the  break,  and  the  light 
in  the  tube  is  not  perfectly  steady.  In  order  to  avoid  varia- 
tions in  the  operation  of  the  interrupter  due  to  changes 
in  the  primary  current,  and,  therefore,  in  the  magnetization 
of  the  core,  there  is  sometimes  provided  a  small,  separate 
magnet  operated  by  an  independent  circuit.  In  the  mer- 
cury dip  a  silver  needle  is  alternately  plunged  into  and 
raised  from  a  cup  containing  mercury  covered  with  a  layer 
of  petroleum.  The  time  occupied  by  the  passage  of  the 
current  may  be  increased  by  lengthening  the  needle.  An 
American  firm  makes  a  dip  interrupter  in  which  the  make 
can  be  so  synchronized  as  to  take  only  the  crests  of  alter- 
nating waves,  and  thus  convert  an  alternating  into  a  direct 
current.  In  the  Mackenzie  Davidson  break  a  segmented 
copper  disk  rotates  at  an  oblique  angle  to  the  surface  of 
the  mercury. 

The  Mercury  Jet  or  Turbine. — Cunningham's  modifica- 
tion consists  of  a  closed  vessel,  the  bottom  of  which  forms 
a  well  containing  mercury.  Into  this  dips  a  perpendicular 
tube  containing  a  rotary  pump,  open  below  the  surface  of 
the  mercury,  with  a  pivot  fitting  into  a  bearing  below. 
Above,  the  tube  is  continuous  with  a  spindle  projecting 
through  the  cover  of  the  vessel. 

About  half-way  toward  the  top  of  the  vessel,  the  tube 
divides  into  two,  passing  out  at  right  angles  in  opposite 
directions,  each  terminating  in  a  fine  opening.  In  close 
proximity  to  the  inner  wall  of  the  vessel  are  two  metallic- 
sectors,  each  occupying  about  one-quarter  of  the  circum- 
ference, and  connected  each  with  a  binding  post  projecting 
above  the  cover.  By  means  of  these  the  apparatus  is  intro- 
duced into  the  circuit  before  it  enters  the  coil.  Belting 
connected  with  a  small  motor,  or,  in  case  a  motor  generator 


548    GENERAL  TREATMENT  AND  METHODS 

is  used  to  energize  the  coil,  connected  directly  to  the  latter, 
serves  to  rapidly  revolve  the  spindle,  and  with  it  the  system 
of  tubes.  The  mercury  is  drawn  up  from  the  well  and 
projected  in  a  fine  spray  against  the  wall  of  the  vessel,  to 
fall  back  into  the  well  at  the  bottom.  During  a  part  of  each 
revolution  the  spray  impinges  against  the  metallic  sectors 
above  mentioned,  at  which  time  the  circuit  is  closed  from 
one  sector,  through  the  mercury  spray,  to  the  other.  If  the 
extra  direct  current  be  not  fully  taken  up  by  the  condenser 
there  will  be  much  sparking  within  the  apparatus,  and  an 
oxide  mixed  with  pulverized  mercury,  in  the  form  of  a 
grayish  powder,  is  rapidly  formed,  clogging  the  tubes,  and 
requiring  frequent  cleansing.  With  the  condenser  set  at 
its  proper  capacity,  however,  this  interrupter  can  be  used 
many  times  daily  for  a  year  or  more  without  demanding 
attention.  A  special  form  of  this  device  plso  serves  to 
convert  an  alternating  into  a  direct  current.  In  the  German 
instruments  the  spray  is  fixed  while  the  sectors  revolve, 
and  the  break  takes  place  in  oil. 

An  ingenious  modification  of  the  mercury-jet  interrupter 
is  known  as  the  autonome.  In  this  arrangement  the  inter- 
rupter is  connected  with  the  motor  both  mechanically  and 
electrically,  so  that  the  same  interruption  serves  both  for 
the  coil  and  the  interrupter.  The  rotations  must  be  started 
by  the  hand. 

The  electrolytic  interrupter  is  well  adapted  to  short  runs, 
as  for  radiography,  but  does  not  answer  for  longer  expo- 
sures such  as  are  used  in  treatment,  as  well  as  the  mechani- 
cal devices.  It  can  only  be  used  with  heavy  voltages.  It 
yields  an  especially  large  output  at  the  secondary  terminal 
within  a  given  time.  The  electrolytic  interrupter,  of  which 
Wehnelt's  is  the  type,  consists  essentially  of  a  lead  electrode, 
exposing  a  large  surface,  and  connected  with  the  negative 
pole,  and  one  or  several  platinum  electrodes,  exposing  a 
small  surface,  and  connected  with  the  positive  pole.  Both 
are  plunged  into  an  electrolyte,  such  as  dilute  sulphuric 
acid.  The  platinum  electrode  is  enclosed  in  a  porcelain 
cylinder  provided  with  a  small  opening  at  its  lower  end.  In 


THE  X-RAYS  549 

consequence  of  the  high  resistance  to  the  passage  of  the 
current  offered  by  the  small  surface  of  fluid  in  contact 
with  the  anode,  the  fluid  at  such  contact  is  rapidly  heated 
and  forms  a  layer  of  vapor  about  the  anode.  The  extra 
resistance,  so  introduced,  considerably  reduces  the  current. 

This  reduction  brings  into  existence  by  self-induction  in 
the  primary  an  extra  current,  which  produces  electrolytic 
decomposition  of  the  layer  of  vapor  into  its  component 
oxygen  and  hydrogen.  These  gases  suddenly  combining 
by  their  explosion  form  an  absolutely  non-conducting  space 
about  the  anode,  and  complete  the  interruption.  The 
fluid  once  more  coming  into  contact  with  the  anode,  the 
same  process  is  repeated  several  hundred  times  a  second. 
The  strength  of  current  yielded  by  the  machine  will  depend 
upon  the  voltage  of  the  inducing  current,  the  self-induction 
in  the  primary,  and  the  extent  of  anode  surface  exposed  to 
the  electrolyte.  If  the  platinum  of  the  anode  be  pushed 
farther  out  from  its  insulating  porcelain  cylinder,  the  cur- 
rent will  be  increased,  but  the  interruptions  will  be  less 
rapid.  If  the  rheostat  be  pushed  back  toward  zero,  both 
the  current  and  the  frequency  of  interruption  will  be 
increased.  With  this  type  of  interrupter  no  condenser  is 
required. 

The  objections  to  this  interrupter  are  the  frequent 
breaking  of  porcelain  cylinders,  caused  by  explosions  of 
the  mixed  gases;  that  it  will  not  operate  with  low  voltages; 
and  that  when  long  in  action  the  liquid  becomes  heated 
and  the  interruptions  become  irregular  or  cease.  The 
latter  difficulty  may  be  in  part  obviated  by  passing  a  current 
of  cold  water  through  a  coil  in  the  jar,  or  by  using  large 
jars.  During  use  a  bubble  of  gas  may  collect  over  the 
anode,  preventing  contact  and  thus  stopping  the  appa- 
ratus. Shaking  the  anode,  or  momentarily  reversing  the 
current,  will  dislodge  the  bubble. 

The  electrolytic  interrupter  can  be  used  to  convert  an 
alternating  into  a  unidirectional  current,  although  results 
so  obtained  are  not  as  good  as  when  the  original  curnvnt 
is  unidirectional. 


550    GENERAL  TREATMENT  AND  METHODS 

The  Caldwell-Simon  liquid  interrupter  does  not  operate 
by  electrolysis.  It  is  thus  described  by  Mr.  Caldwell: 
"It  consists  of  a  jar  containing  dilute  sulphuric  acid, 
within  which  is  a  cup  of  insulating  material  perforated  by 
a  small  hole.  Lead  electrodes  are  placed  in  the  outer  jar 
and  in  the  insulating  cup. 

"  When  the  primary  current  of  an  induction  coil  is  passed 
through  this  apparatus,  there  is  comparatively  little  heat- 
ing of  the  liquid,  except  in  the  aperture  connecting  the  two 
chambers,  where  the  current  density  is  very  large  on  account 
of  the  small  area  of  the  aperture.  At  this  point,  therefore, 
sufficient  heat  is  developed  to  vaporize  rapidly  the  liquid, 
and  bubbles  of  steam  which  form  break  the  connection 
between  the  liquid  in  the  inner  jar  and  that  in  the  outer 
jar.  As  soon  as  the  current  is  broken  the  heating  stops, 
and  the  two  portions  of  the  liquid  come  together  again, 
completing  the  circuit." 

Increasing  the  frequency  of  interruption  increases  the 
sharpness  of  the  break  and,  therefore,  the  voltage  in  the 
secondary  circuit.  Increasing  the  time  allowed  for  flow 
at  the  expense  of  break,  within  certain  limits,  increases 
secondary  voltage.  Whether  this  means  higher  electro- 
motive force,  or  more  current,  will  depend  upon  several 
considerations  which  cannot  here  be  discussed. 

The  Milliammeter. — In  order  to  show  the  actual  amount 
of  current  passing  through  the  tube,  one  may  use  a  milli- 
ammeter  interposed  in  the  tube  circuit.  It  also  detects  the 
presence  of  an  inverse  current  and  indicates  a  rise  or  fall 
in  the  vacuum  in  the  tube.  \Vhile  of  value  as  an  additional 
datum  for  the  comparison  of  technique,  it  cannot  be  con- 
sidered an  essential  part  of  the  outfit.  At  best  it  does  not 
tell  us  the  wattage,  which  would  be  the  only  real  measure 
of  the  efficiency  of  the  secondary  circuit. 

The  Tube. — The  physics  concerned  in  the  production  of 
the  rays  have  already  been  set  forth  in  part  (see  p.  538). 
It  remains  for  us  to  consider  the  factors  which  affect  the 
rays,  and  the  important  modifications  in  design  and  con- 
struction of  tubes. 


THE  X-RAYS  551 

Tubes  are  spoken  of  as  hard,  medium,  or  soft,  according 
to  their  penetrability  by  the  current.  A  hard  tube  requires 
for  its  operation  a  greater  number  of  watts  (1  volt  x  1 
ampere  =  1  watt)  which  is  indicated  by  a  longer  equivalent 
spark  at  the  parallel  gap.  A  "hard"  tube  is  one  enclosing 
a  high  vacuum,  while  a  "soft"  tube  has  a  low  vacuum,  that 
is  to  say,  contains  a  greater  number  of  air  molecules.  A 
hard  tube  emits  a  smaller  quantity  of  rays  than  a  soft 
tube,  but  of  deeper  penetration.  It  at  the  same  time 
generally  emits  a  small  number  of  rays  of  low  penetration, 
whereas  all  the  rays  emitted  by  a  soft  tube  are  of  this 
character.  Increasing  the  current  through  a  tube  not  only 
increases  the  total  number  of  rays  emitted,  but  makes 
some  of  them  more  penetrating.  To  suppose  that  the  same 
tube  is  less  active  therapeutically  when  brilliantly  illumi- 
nated by  an  increase  of  current  than  when  emitting  a 
dimmer  light,  because  in  the  former  case  it  gives  a  clear 
fluoroscopic  image  showing  more  penetrating  rays,  would 
be  an  error,  since,  as  we  have  just  said,  under  such  circum- 
stances the  total  rays  are  increased,  a  large  proportion  of 
which  are  of  the  requisite  degree  of  softness.  These, 
however,  are  not  detected  by  the  fluoroscope.  Soft  or 
medium  tubes  are  best  adapted  to  radiotherapy. 

It  is  important  to  note  that  the  vacuum  in  a  tube  is  a 
constantly  varying  quantity.  As  a  rule,  the  longer  a  tube  is 
used  the  harder  it  becomes;  rarely  the  opposite  occurs.  If 
a  tube  be  overdriven  it  will  become  rapidly  harder,  although 
sometimes  when  crowded  until  the  target  becomes  red-hot 
it  softens  again.  The  reason  of  this  will  be  apparent  when 
we  come  to  consider  the  subject  of  the  regulation  of  tubes. 
Often  a  tube  will  vary  in  hardness,  and,  therefore,  in  the 
character  of  rays  emitted,  while  being  used,  indeed,  within 
a  few  minutes.  Hardening  is  due  to  absorption  of  residua] 
electrons  by  the  anticathode  and  glass  under  the  influence 
of  bombardment. 

The  brass  caps  over  the  tube  terminals  will  sometimes 
pull  off.  They  can  be  easily  stuck  on  again  with  i>  mixture 
of  plaster  of  Paris  and  liquid  glue.  It  is  not  necessary  to 


552    GENERAL  TREATMENT  AND  METHODS 

bring  the  wire  which  projects  from  the  glass  into  exact 
contact  with  the  cap. 

Regulation  of  Tubes. — The  operator  should  be  provided 
with  several  tubes  and  change  them  from  time  to  time.  A 
tube  which  has  become  too  hard  for  therapeutic  efficiency 
will  often  improve  on  being  laid  aside  for  a  few  months. 
Heating  tends  to  lower  the  vacuum  by  bringing  about  a 
liberation  of  the  absorbed  gas,  thus  explaining  the  occa- 
sional softening  of  an  overdriven  tube,  as  mentioned 
above.  Some  degree  of  softening  may  be  obtained  by 
carefully  heating  over  a  spirit  or  Bunsen  flame,  or  baking  in 
an  oven  at  300°  F.  for  several  hours.  Many  tubes  have 
regulating  devices  attached  to  them,  which  may  require 
the  use  of  a  spirit  flame  or  be  automatic. 

The  osmoregulator  consists  of  a  small  tube  at  right 
angles  to  the  shaft  of  the  focus  tube,  into  which  is  soldered 
a  platinum  wire;  a  removable  cap  fits  over  it.  When  it  is 
desired  to  lower  the  vacuum,  the  cap  is  removed  and  the 
wire  held  in  the  flame  of  a  spirit  lamp  or  gas  jet  until  heated 
to  a  cherry  red.  This  makes  it  porous  and  allows  hydrogen 
to  pass  from  the  flame  through  the  wire  into  the  tube. 

Self-regulating  Tubes. — In  Miiller's  tube  a  second  smaller 
chamber  connects  directly  with  the  larger  bulb.  Into  this 
smaller  chamber  are  fitted  a  supplementary  anode  and 
cathode.  The  cathode  terminates  in  mica  plates  between 
which  is  placed  ?  substance  which,  on  heating,  will  liberate 
gas.  The  anode  terminates  in  a  coil  of  fine  platinum  wire. 
To  the  cathodal  end  is  fitted  an  arm  consisting  of  a  wire  so 
jointed  that  its  other  end  can  be  approached  to  the  principal 
cathode  or  pushed  away  from  it.  Now  when  the  vacuum 
within  the  tube  is  raised  so  that  its  resistance  is  greater  than 
that  outside  the  tube  from  the  main  cathode  to  the  end  of 
the  wire,  there  is  sparking  across  the  latter  interval.  The 
current  now  being  deflected  heats  the  cathode  in  the  lesser 
chamber  and  liberates  gas  until  the  vacuum  is  so  lowered 
as  to  permit  the  passage  of  the  current  across  the  main  tube. 
If  the  vacuum  become  too  low,  it  can  be  again  raised  by 
connecting  the  positive  wire  to  the  secondary  anode.  The 


THE  X-RAYS  553 

circuit  being  closed,  minute  metallic  particles  are  projected 
from  the  fine  coil  at  the  anode  to  the  glass  immediately 
about  it,  thus  combining  with  and  fixing  a  number  of  gas 
molecules,  and  consequently  raising  the  vacuum. 

The  Sayen  tube,  made  by  Queen  and  Co.,  has  the  gas- 
producing  compound  in  a  small  bulb  connecting  with'  the 
main  tube,  but  separated  from  the  auxiliary  cathode  by  a 
closed  chamber  at  a  lower  vacuum.  When  the  wire  from 
the  auxiliary  cathode  is  brought  close  to  the  main  cathode 
terminal,  discharge  occurs  through  this  chamber,  heating 
the  small  tube  and  contained  compound. 

In  the  Thomson  tube  a  small  quantity  of  potassic  or 
sodic  hydrate  is  placed  in  an  auxiliary  bulb  through  which 
is  sealed  a  platinum  electrode.  The  latter  may  be  heated 
with  a  lamp,  or  the  device  may  be  made  automatic  by 
bringing  a  wire  from  the  electrode  near  the  cathodic  ter- 
minal. In  all  self-regulating  tubes  there  is  a  danger  of 
making  the  vacuum  too  low.  Regulation  is  effected  by 
leading  the  current  away  from  the  main  terminals.  This 
permits  the  target  to  cool  off  and  occlude  some  gas.  When 
the  current  returns  to  its  usual  path  it  is  again  heated  and 
the  gas  liberated,  thus  bringing  the  vacuum  lower  than  was 
designed. 

Special  forms  of  tube  intended  for  work  within  the  mouth 
or  other  cavities  need  not  be  here  described.  Most  thera- 
peutic work  can  be  satisfactorily  done  with  the  smaller, 
simpler,  and,  therefore,  less  expensive  tubes,  but  heavier 
targets  will  be  required  for  use  with  coils  than  with  static 
machines. 

New  tubes  always  work  better  than  old;  still,  with  care  a 
tube  may  continue  efficient  for  months.  Inasmuch  as  all 
tubes  tend  to  harden  with  age,  and  as  soft  or  medium  tubes 
are  needed  for  therapy,  a  tube  that  is  no  longer  suited  to 
the  latter  purpose  may  be  at  its  best  for  radioscopy  or 
radiography. 

The  Tube  Stand. — This  should  be  of  sufficient  height 
to  rest  upon  the  floor  and  raise  the  tube  to  a  maximum 
elevation  of  five  feet;  smaller  stands  for  use  on  a  table  do 


554    GENERAL  TREATMENT  AND  METHODS 

not  allow  a  perfect  adjustment  of  the  tube  to  the  surface 
to  be  rayed,  and  are  likely  to  fall  over.  The  base  should 
be  sufficiently  heavy  to  make  the  whole  quite  secure.  An 
extensible  arm  with  a  second  joint  should  permit  of  changes 
of  position  in  any  direction.  It  is  a  good  idea  to  carry  the 
lead  wires  toward  the  ceiling  between  the  coil  and  stand, 
so  as  to  have  them  well  out  of  the  way. 

Protection  of  the  Patient  and  Operator. — It  is  of  the 
highest  importance  that  only  those  parts  of  the  patient's 
surface  which  require  them  should  be  exposed  to  the  rays. 
Fortunately  this  end  is  in  all  but  rare  instances  easily 
secured.  The  more  complicated  devices  originally  devised 
have  given  way  to  the  simple  interposition  of  an  opaque 
shield  between  the  tube  and  patient.  The  simplest  plan 
is  to  use  sheet-lead  -£$  to  -£%  inch  thick  (Pusey),  or  thick 
tinfoil  (3^  ft.  to  the  lb.),  in  which  is  cut  a  hole  of  the  de- 
sired shape  and  size.  The  shield  should  be  large  enough 
to  cover  all  surfaces  looking  toward  the  tube  and  within  a 
foot  of  it.  The  shields  can  be  laid  on  the  surface  or  bound 
to  the  part.  A  layer  of  non-conducting  material  on  the 
under  surface  of  the  shield,  except  when  working  with  hard 
tubes  giving  high  external  electrostatic  effects,  is  an  unnec- 
essary refinement.  There  is  no  advantage  in  a  "ground." 
There  should  be  no  sharp  points  or  creases  about  the 
edges,  as  painful  sparking  may  occur  between  such  points 
and  the  skin.  If  the  rays  are  directed  to  a  point  on  the  head 
or  face,  it  may  be  necessary  to  protect  the  shoulders  with  a 
second  shield.  The  above  precautions  will  be  sufficient 
in  ordinary  cases  in  which  sittings  are  continued  during 
one,  two,  or  three  months.  When  sittings  are  to  be  pro- 
longed over  many  months,  however,  it  may  be  desirable  to 
use  more  complete  protection  to  guard  against  the  action 
of  rays  upon  more  distant  parts  of  the  body.  The  patient 
may  under  such  circumstances  be  exposed  to  certain  dan- 
gers which  ordinarily  threaten  the  operator  only,  to  be 
mentioned  later. 

Another  form  of  shield  is  supported  upon  an  independent 
base  or  attached  by  an  extensible  arm  to  the  upright  shaft 


THE  X-RAYS  555 

of  the  tube  stand.  This  form  usually  consists  of  a  series 
of  diaphragms  of  various  apertures. 

Best  of  all,  perhaps,  are  the  devices  by  which  the  tube  is 
enclosed  in 'a  casing  impervious  to  the  rays,  and  with  an 
opening  opposite  to  the  anticathode.  This  arrangement  has 
the  advantage  of  protecting  not  only  the  patient,  but  the 
other  occupants  of  the  room  as  well.  A  similar  end  may 
be  accomplished  by  a  simple  box  covered  with  sheet-lead 
and  secured  to  the  stand,  as  described  by  Dr.  Stelwagon. 
A  very  satisfactory  home-made  arrangement  can  be  made 
out  of  one  of  the  pasteboard  boxes  in  which  tubes  are  sold. 
A  hole  is  made  in  the  bottom  of  the  box  so  that  a  line 
produced  through  the  anticathode  will  pass  through  its 
centre.  Its  cross  diameter  should  equal  half  the  distance 
from  the  anticathode  to  its  centre.  As  the  rays  cut  the 
bottom  of  the  box  at  an  angle,  the  hole  should  be  an  oval, 
its  diameter  parallel  to  the  long  axis  of  the  box  being  some- 
what the  shorter.  The  lead  wires  pass  through  small  holes 
at  each  end  of  the  box.  Two  cross-pieces  of  wood  secured 
across  the  top  serve  to  fix  the  box  to  the  horizontal  arm  of 
the  tube  stand.  The  box  should  now  receive  seven  coats 
of  white-lead  paint,  both  inside  and  out.  With  a  brilliantly 
illuminated  tube  the  fluoscope  will  still  detect  some  rays 
penetrating  the  fourteen  coats  of  paint,  but  experience 
seems  to  show  that  the  protection  thus  afforded  is  sufficient. 
This  may  be  explained  not  only  by  the  fewness  of  the  rays 
which  make  their  way  through,  but  further  by  the  fact  that 
those  few  are  of  the  more  penetrating  and  less  active  sort — 
the  less  penetrating  active  rays  being  probably  all  blocked 
off.  If  desirable,  diaphragms,  or  a  funnel-shaped  pro- 
tractor, may  be  attached  to  the  opening  left  for  the  rays. 
The  top  of  the  box  may  be  left  open,  allowing  the  operator 
to  see  the  tube  and  judge  of  its  illumination.  A  sheet  of 
aluminum  interposed  between  tube  and  patient  can  only 
be  of  use  in  treating  deep  growths,  where  soft  rays  are  not 
wanted. 

Here  should  be  mentioned  Piffard's  tube,  made  of  a 
cobalt  glass  impervious  to  the  rays,  except  where  a  window 


556    GENERAL  TREATMENT  AND  METHODS 

of  permeable  glass  is  inserted  opposite  the  anticathode, 
but  not  parallel  to  it.  It  is  objected  that  here,  as  in  Belot's 
"localizer,"  the  most  intense  irradiation  is  cut  off.  The 
objection  is  less  weighty  than  at  first  seems,  since  the 
number  of  rays  diminish  very  slowly  from  centre  to 
periphery  (see  p.  563).  With  such  a  choice  of  rays  the 
inconvenient  cathode  shank  is  no  longer  in  the  way. 

Protection  of  the  Operator. — Every  large  city  can  show 
one  or  more  physicians  seriously  crippled  by  the  rays. 
Such  examples  give  us  pause.  The  lesson  to  be  derived 
from  them  is,  sedulously  to  avoid  all  unnecessary  exposure, 
especially  the  dangerous,  rash,  not  to  say  foolhardy  prac- 
tice of  constantly  using  the  operator's  hand  for  a  shadow 
test.  The  experienced  man  need  only  resort  to  this  method 
at  rare  intervals,  and  then  a  glance  should  suffice.  Another 
important  point  is  to  keep  within  that  part  of  the  room 
corresponding  to  the  dark  hemisphere  of  the  tube.  Even 
then  some  rays  will  reach  the  operator,  and  their  accumu- 
lated influence  during  years  of  work  may  cause  sterility, 
if  not  dermatitis  or  other  tissue  changes.  It  is,  therefore 
well  for  him  to  provide  some  safe  place  to  which  he  may 
retire,  such  as  a  lead-covered  screen  provided  with  a  glazed 
window,  or  he  may  step  just  outside  the  door  and  around 
the  partition  wall,  if  the  latter  be  not  of  wood,  taking  an 
occasional  glance  into  the  room.  It  is  also  well  to  wear  a 
short  apron  of  sheet-lead  or  tinfoil  to  shield  the  testicles. 

The  many  devices  in  the  way  of  lead  or  tinfoil  armor, 
gloves  covered  with  tinfoil,  etc.,  are  cumbersome  and  not 
practical.  Buckskin  gloves  covered  with  a  coat  of  lead 
paint  are  an  insufficient  protection.  The  various  plans  for 
enclosing  the  tube  are  a  great  protection  to  the  operator. 
The  impunity  secured  by  caution  is  illustrated  by  Pusey's 
statement  that  neither  he  nor  his  assistants  have  ever 
experienced  the  slightest  dermatitis.  We  can  make  the 
same  statement,  although  one  of  us  has  given  upward  of 
ten  thousand  sittings  in  the  last  five  years. 

Choice  and  Dosage  of  Rays. — The  effects  of  the  rays 
upon  living  tissue  depend  upon  two  factors:  the  quality 


THE  X-RAYS  557 

of  the  rays,  that  is,  their  power  of  penetration,  and  the 
total  quantity  of  these  absorbed.  The  latter  is  determined 
by  the  quantity  emitted  by  the  tube,  the  distance  of  the  latter 
from  the  surface,  and  the  total  time  occupied  in  sittings. 
The  time  evidently  varies  as  the  number  and  duration  of 
sittings. 

Quality  of  the  Rays. — Rays  vary  in  penetration.  As 
before  stated,  hard  tubes  emit  comparatively  few  rays  of 
high  penetration,  and  soft  tubes  many  rays  of  low  pene- 
tration. The  former  are  best  adapted  to  radioscopy  and 
radiography,  and  the  latter  to  radiotherapy.  The  quantity 
being  the  same,  "  soft"  rays,  that  is,  rays  of  low  penetration, 
will  act  more  powerfully  upon  tissues,  whether  for  good 
or  ill,  than  "hard"  rays,  since  the  latter  continue  through 
the  tissues  with  little  change,  whereas  the  former  are 
absorbed  by  the  tissues  and  thus  liberate  their  energy  in 
them. 

One  may  judge  of  the  degree  of  penetration  of  the  rays 
by  the  fluoroscope,  which  consists  of  a  screen  covered  with 
a  substance  fluorescent  to  the  rays,  of  which  barium 
platinocyanide  is  the  best,  placed  at  the  larger  end  of  a 
light-tight  box,  and  viewed  by  the  operator  through  an 
opening  at  the  smaller  end,  so  constructed  as  to  fit  accu- 
rately over  the  face  around  the  eyes.  With  rays  of  low 
penetration,  such  as  are  desirable  in  all  cutaneous  therapy, 
the  bones  of  the  hand  will  throw  a  solid  shadow  on  the 
screen,  while  the  soft  parts  will  show  of  a  gray-green 
shade,  the  rest  of  the  screen  being  well  illuminated.  If 
the  bones  show  transparent,  so  as  to  reveal  the  differences 
in  density  between  their  shafts  and  extremities,  the  rays 
are  too  penetrating.  The  operator  should  avoid  using  his 
hand  any  longer  or  any  oftener  than  is  necessary  in  these 
determinations,  lest  he  suffer  serious  injury.  In  practice, 
the  experienced  operator  need  rarely  resort  to  this  method 
while  using  a  tube  with  which  he  is  familiar.  Hardening 
of  the  tube  will  be  revealed,  the  voltage  and  amperage  of 
the  primary  remaining  the  same,  by  sparking  across  the 
parallel  gap. 


558    GENERAL  TREATMENT  AND  METHODS 

A  more  exact  method,  however,  was  devised  by  Rontgen 
for  measuring  the  penetration  of  the  rays.  His  platinum- 
aluminum  window  is  modified  in  the  radiochromometer 
of  Benoist. 

This  instrument  is  based  on  the  facts  that  metals  vary 
in  opacity  to  the  rays  as  their  atomic  weights,  or,  in  other 
words,  their  densities,  and  that  the  ratio  of  their  opacities 
varies  with  the  penetrating  power  of  the  rays.  Thus, 
quoting  Belot:  "Supposing  aluminum  is  5  times  as  trans- 
parent as  silver  for  soft  o>rays,  it  will  be  10  times,  20  times, 
30  times  as  transparent  for  rays  of  greater  hardness. 

"  The  radiochromometer  is  formed  of  a  disk  of  aluminum 
divided  into  twelve  sectors  whose  thickness  varies  from  1 
to  12  mm.  The  aluminum  disk  is  pierced  by  a  central 
aperture  in  which  is  placed  a  plate  of  silver  0.11  mm.  in 
thickness.  The  sectors  are  arranged  like  the  figures  on  a 
clock  face,  thus  enabling  any  one  of  them  to  be  easily 
recognized  by  its  position.  No.  1  is  in  the  position  corre- 
sponding to  one  o'clock,  No.  12  corresponding  to  that  of 
twelve  o'clock. 

"The  apparatus  is  used  either  in  front  of  a  fluorescent 
screen  or  above  a  photographic  plate.  In  either  case,  one 
of  the  sectors  will  match  the  tint  of  the  central  disk.  The 
number  of  this  sector  will  indicate  the  radiochromometric 
intensity  of  the  x-rays  employed.  This  number  will  suffice 
to  define  the  quality  of  the  rays  in  question." 

The  measurements  so  obtained,  however,  only  apply  to 
the  most  penetrating  rays  emitted  at  the  time.  Besides 
these  there  are  also  present  softer  rays,  for  a  focus  tube 
gives  out  simultaneously  rays  of  different  degrees  of  pene- 
tration. 

Quantity  of  Rays  Absorbed. — The  importance  of  deter- 
mining the  quantity  of  rays  is  evident  from  Kienbock's 
generally  accepted  dictum  that,  "The  degree  of  reaction 
depends  upon  the  quantity  of  x-rays  absorbed  by  the  skin." 
Of  course,  this  is  not  the  same  thing  as  the  quantity  falling 
upon  the  skin,  since  the  more  penetrating  rays  are  not 
absorbed  to  the  same  extent  as  those  that  are  less  so,  but 


THE  X-RAYS  559 

in  the  absence  of  more  exact  knowledge  we  may  take  one 
of  these  quantities  as  an  approximation  to  the  other. 

Distance. — The  first  factor  to  be  considered  is  that  of 
distance.  This  should  properly  be  measured  from  the 
point  of  origin  of  the  rays,  that  is,  the  anticathode,  to  the 
surface  of  the  patient,  and  not  from  the  outside  of  the  tube. 
The  ovrays,  like  all  forms  of  radiant  energy,  obey  the  law  of 
the  inverse  square,  that  is,  their  intensity  (number  of  rays 
falling  on  a  given  area)  varies  inversely  as  the  square  of  the 
distance.  A  practical  deduction  from  this  law,  amply 
supported  by  sad  experience,  is  that  the  tube  should  never 
be  brought  closer  to  the  surface  than  is  necessary  to  secure 
the  desired  effect.  It  is  probably  well  to  observe  five  inches 
measured  from  the  anticathode,  as  a  minimum  distance, 
rarely  to  be  approached.  Earlier  operators  often  worked 
with  shorter  distances,  some  even  bringing  the  glass  in 
contact  with  the  surface,  a  practice  which  occasioned  some 
disastrous  results.  As  a  general  rule,  it  is  said  that  the 
distance  of  the  anticathode  should  be  twice  the  diameter 
of  the  surface  to  be  irradiated,  but  this  rule  will  not  apply 
to  the  treatment  of  very  small  surfaces. 

When  it  is  desirable  to  act  through  a  considerable  thick- 
ness of  tissue  a  tube  yielding  a  large  number  of  rays 
placed  at  a  greater  distance  will  give  better  results  than 
one  yielding  fewer  rays  brought  close  to  the  surface.  By 
the  former  arrangement  we  secure  greater  uniformity  of 
action  throughout  the  depth  we  desire  to  affect,  so  that 
while  those  portions  of  tissue  near  the  surface  will  receive 
no  larger  a  dose  than  they  should,  those  at  a  greater  depth 
will  still  receive  enough  to  be  of  benefit.  The  following 
illustration  will  make  this  evident :  Suppose  we  arbitrarily 
call  the  volume  of  rays  falling  upon  a  given  area  at  one 
inch  from  their  source,  1.  Then  if  such  source  be  three 
inches  from  the  surface,  the  volume  of  rays  at  the  surface, 
by  the  law  of  the  inverse  square,  will  be  represented  by  ^, 
and  for  the  same  area  at  a  depth  of  three  inches,  or  six  inches 
from  their  origin,  by  ^g-.  If  now  the  point  of  origin  be 
removed  to  a  distance  of  six  inches,  the  volume  impinging  on 


560    GENERAL  TREATMENT  AND  METHODS 

the  surface  will  be  represented  by  ^,  while  at  a  depth  of 
three  inches  below  the  surface,  or  nine  inches  from  the 
source  of  the  rays,  it  will  be  only  -^.  Now,  in  the  first 
case,  the  volume  at  the  surface  is  four  times  that  at  a  depth 
of  three  inches,  while  in  the  second  it  is  only  two  and  one- 
quarter  times  as  much. 

At  the  first  sitting  the  tube  should  not  be  nearer  than  six 
inches,  and  in  most  cases  eight,  and  be  gradually  approxi- 
mated at  later  sittings.  Such  at  least,  is,  as  we  believe,  the 
practice  of  most  operators  in  this  country.  It  is  evident 
that  no  definite  set  of  rules  can  be  given  to  govern  this 
point.  The  operator's  judgment,  based  upon  experience, 
will  be  the  best  guide. 

The  subject  of  distance  will  be  further  considered  when 
we  come  to  consider  the  question  of  the  quantity  of  rays 
emitted  by  the  tube  (see  p.  563). 

Time. — The  second  factor  affecting  the  matter  of  the 
quantity,  or  total  number  of  rays  absorbed  by  the  patient 
throughout  his  treatment,  is  that  of  time. 

In  the  absence  of  precise  methods  of  measurement,  such 
as  were  detailed  in  the  last  section,  no  definite  rules  can  be 
laid  down  as  to  the  duration  or  number  of  sittings,  except 
that  the  first  should  begin  with  a  minimum  of  say,  five,  or 
even,  with  a  very  active  tube,  two  minutes,  and  be  gradually 
increased  to  a  maximum  of  ten,  or,  possibly,  in  exceptional 
instances,  fifteen  minutes.  Eight  minutes  is  about  right 
for  most  cases.  The  proper  interval  between  treatments 
will  also  vary  according  to  the  requirements  of  the  case. 
Time  and  distance  can  evidently  be  made  to  balance  each 
other.  Thus,  if  a  certain  quantity  of  rays  fall  upon  a  given 
area  within  a  certain  time,  with  the  tube  at  a  certain  dis- 
tance, we  can  obtain  the  same  quantity  with  a  greater 
distance  and  longer  time.  Remembering  the  law  of  the 
inverse  square,  as  applied  to  the  first  of  these  factors,  we 
would  correct  its  effect  by  multiplying  the  time  by  the 
square  of  the  distance.  Thus,  if  a  certain  effect  is  ob- 
tained at  3  inches  in  8  minutes,  we  can  secure  the  same 
at  6  inches  (twice  the  distance)  in  22  x  8,  or  32  minutes. 


THE  X-RAYS  561 

The  longer  the  sittings  and  the  shorter  the  intervals,  the 
greater  evidently  is  the  risk  of  injury  from  the  rays.  We 
are  largely  influenced  in  our  judgment  as  to  the  degree  of 
risk  of  injury  to  which  it  is  proper  to  expose  our  patient  by 
the  gravity  of  the  condition  from  which  he  seeks  relief. 
Thus,  it  may  be  justifiable  to  expose  an  infiltrating  and 
inoperable  carcinoma  to  daily  irradiations,  while  the  same 
practice  would  be  highly  reprehensible  in  dealing  with  a 
hypertrichosis.  Patients  from  the  country  or  from  distant 
cities  will  often  urge  us  to  give  them  daily  sittings  in  order 
that  they  may  the  sooner  return  to  their  homes.  At  such 
times  we  should  carefully  keep  in  mind  the  ultimate  welfare 
of  the  patient  as  the  first  consideration. 

Patients  entering  upon  a  course  of  treatment  quite  nat- 
urally wish  to  know  how  many  sittings  will  be  required. 
Unfortunately  we  can  at  best  limit  our  answer  between  a 
widely  separated  minimum  and  probable  maximum,  with 
a  reservation  in  regard  to  the  latter.  The  operator  of 
experience  can  say  that  most  cases  of  the  sort  in  question 
have  required  no  more  than  a  certain  number  of  sittings, 
but  unless  he  be  neither  honest  nor  shrewd  he  will  make 
the  patient  clearly  understand  that  the  rule  presents  many 
exceptions. 

Quantity  of  Rays  Emitted  by  the  Tube  in  a  Given  Time. — 
One  can  form  a  fair  estimate  of  this  important  factor  by 
the  sharpness  with  which  the  illuminated  hemisphere  is 
cut  off,  and  its  brilliancy.  Still  more  significant,  perhaps, 
is  the  glow  of  the  fluorescent  screen.  These  data  are. 
perhaps,  sufficient  to  the  trained  worker  for  all  practical 
purposes,  and  are  generally  so  considered  in  this  country. 
For  more  exact  determinations,  however,  special  methods 
have  been  devised.  They  are  all  based  upon  the  chemical 
activity  of  the  rays,  and  depend  upon  certain  color  changes 
in  known  media.  Chief  among  devices  for  this  end  is  the 
chromoradiometer  of  Holzknecht.  This  consists  of  pastilles 
containing  a  reagent,  and  a  graduated  color  scale  for  com- 
parison. Each  shade  of  the  scale  is  marked  with  a  number 
expressing  multiples  of  an  arbitrary  unit  quantity  of  rays. 
36 


562         GENERAL  TREATMENT  AND  METHODS 

The  symbol  for  this  unit  is  H.  There  are  twelve  shades 
ranging  from  3  H  to  24  H.  A  pastille  attached  to  a  card,  on 
which  memoranda  may  be  jotted  down,  is  placed  on  the 
skin  near  the  spot  to  be  treated.  The  sitting  is  interrupted 
several  times  until  the  pastille  shows  a  shade  corresponding 
to  the  dose  desired,  as  shown  by  the  color  scale,  or  several 
sittings  may  elapse  before  the  desired  shade  is  obtained. 
In  the  latter  case  the  pastille  should,  between  times,  be 
carefully  protected  from  the  light.  The  same  pastille  may 
be  used  a  number  of  times  until  it  has  attained  the  shade 
indicated  by  24  H,  when  its  color  may  be  restored  by  expo- 
sure to  the  light.  It,  however,  never  completely  recovers 
its  original  shade. 

The  objections  to  the  method  are  the  difficulty  of  deter- 
mining the  very  slight  differences  in  shade,  the  fact  that 
the  change  does  not  always  occur  immediately  (sometimes, 
indeed,  the  full  effect  is  not  visible  until  the  next  day),  the 
fact  that  the  effect  of  a  given  quantity  of  rays  is  not  always 
quite  uniform;  the  difficulty  of  obtaining  the  pastilles, 
their  high  cost,  and  the  fact  that  their  composition  is  kept 
a  secret. 

Freund  devised  a  radiometer  based  on  the  change  of 
color  due  to  the  liberation  of  iodine  in  a  2  per  cent,  chloro- 
form solution  of  chemically  pure  iodoform.  The  solution 
will  not  normally  retain  its  color  more  than  twenty-four 
hours. 

Sabouraud  and  Noire"'s  radiometer  is  made  in  the  same 
manner  as  the  screen  of  a  fluoroscope;  that  is,  it  consists 
of  paper  impregnated  with  an  emulsion  of  collodion  and 
amyl  acetate,  containing  barium  platinocyanide.  The 
paper  grows  darker  on  exposure  to  ar-rays,  and  is  compared 
with  a  water-color  scale  of  2  degrees,  corresponding  to  zero 
and  5  H,  the  latter  being  the  highest  amount  which  can  be 
employed  without  producing  an  initial  erythema. 

The  paper  is  not  to  be  placed  on  the  skin,  as  arc  the 
Holzknecht  pastilles,  but  half-way  between  it  and  the 
anticathode.  The  comparison  with  the  scale  must  be  made 
at  once,  as  the  paper  rapidly  loses  its  color  on  exposure  to 


THE  X-RAYS  563 

the  light.  This  method  possesses  several  advantages  over 
that  of  Holzknecht,  chief  among  which  are  its  non-secrecy 
and  the  fact  that  a  fluorescent  screen,  which  may  be  had  at 
a  moderate  price,  may  be  cut  into  several  thousand  pieces, 
each  sufficient  for  an  exposure,  and  each  capable  of  being 
used  as  many  times  as  one  pleases,  provided  it  be  exposed 
to  the  light  after  each  exposure  until  its  original  color  is 
completely  restored. 

In  the  foregoing  discussion  reference  has  always  been 
had  to  the  largest  quantity  of  rays  emitted  in  any  one  direc- 
tion at  a  given  moment.  This  direction  is  in  a  line  normal 
to  the  plane  of  the  anticathode.  From  this  central  line 
rays  diminish  in  quantity  toward  the  limit  of  the  illuminated 
hemisphere,  the  plane  of  which  coincides  with  that  of  the 
anticathode.  As  we  pass  from  the  centre  of  the  hemisphere 
toward  its  edge,  the  number  of  rays  lessen  very  gradually, 
so  that  at  a  point  84  degrees  around  the  quadrant  the 
rays  are  still  one-half  of  the  maximum. 

To  say  that  at  a  given  angle  a  certain  proportion  of  rays 
are  emitted  does  not  mean,  however,  that  rays  reaching 
the  irradiated  surface  along  that  angle  when  the  plane  of 
the  target  is  parallel  to  that  of  the  surface  will  bear  the 
same  proportion  to  the  number  received  at  the  centre  of  the 
surface.  Still  less  does  it  mean  that  the  relative  reaction  at 
these  two  points  would  be  expressed  by  the  same  figures. 
Far  from  it;  the  observed  reaction  diminishes  much  more 
rapidly  from  the  centre  to  the  circumference  than  these 
figures  would  seem  to  show.  The  reason  for  this  is  tlmt 
two  other  important  factors  are  here  involved.  The  first 
of  these  is,  that  when  the  irradiated  surface  is  approxi- 
mately plane,  the  peripheral  rays  travel  through  a  con- 
siderably greater  distance  before  reaching  it,  and  are, 
therefore,  diminished  in  quantity  by  the  square  of  that 
distance  (the  perpendicular  distance  being  here  the  unit 
of  measurement).  The  second  factor  is  the  law  governing 
all  radiations,  that  is,  that  their  intensity  varies  as  the  sine 
of  the  angle  of  incidence.  The  latter,  manifestly,  dimin- 
ishes as  we  proceed  from  the  perpendicular.  On  a  convex 


564    GENERAL  TREATMENT  AND  METHODS 

surface  both  these  factors  are  increased.  Rays  tangential 
to  the  surface  are  of  no  effect.  A  consideration  of  the  law 
of  the  inverse  square  will  make  it  clear  that  the  closer  the 
tube  is  to  the  surface  the  greater  is  the  disproportion  be- 
tween the  quantity  of  rays  received  at  the  centre  and  at  the 
periphery.  Belot  calculates  that  when  the  distance  from  the 
anticathode  to  the  surface  is  one-half  the  diameter  of  the 
surface,  the  periphery  will  only  receive  one-half  as  much 
as  the  centre;  when  the  diameter  and  distance  are  equal, 
the  periphery  will  receive  three-quarters  as  much  as  the 
centre.  When,  however,  the  distance  is  twice  the  diame- 
ter, the  periphery  will  receive  almost  as  much  as  the 
centre.  As  the  law  of  sines  operates  in  the  same  direction, 
the  obvious  deduction  is  that  the  most  equable  distribution 
of  rays  is  obtained  by  placing  the  anticathode  at  a  distance 
equal  to  two  or  more  times  the  diameter  of  the  surface  to 
be  irradiated.  If  the  surface  be  so  large  as  to  call  for  a 
tube  distance  which  would  require  too  long  a  sitting,  it 
may  be  exposed  a  part  at  a  time. 

Dosage  Concluded. — It  is  claimed  by  Kienbock  and  his 
school,  that  by  applying  the  factors  discussed  in  the  pre- 
ceding sections  a  dose  of  x-rays  can  be  measured  almost 
as  exactly  as  a  dose  of  medicine.  These  factors  are 
quality  and  quantity. 

Quantity  in  turn  depends  upon : 

1 .  The  number  of  rays  emitted  by  the  tube. 

2.  The  distance  of  the  tube  from  the  surface. 

3.  Total  time  of  raying. 

It  has  been  shown  that  there  is  a  compensatory  relation 
between  the  first  two  and  the  last  of  these  elements. 

As  it  is  desirable  to  shorten  the  time  of  sittings  we 
should  be  guided  by  the  dictum  of  Holzknecht,  that  "The 
focus  tube  should  be  placed  as  close  as  is  compatible  with 
equable  irradiation  of  the  skin."  This  distance,  we  have 
seen,  is  not  less  than  twice  the  diameter  of  the  surface. 
\Yr  have  already  noted  an  exception  to  Holzknecht's  rule 
in  the  case  of  a  thick  layer  of  diseased  tissue. 

Suppose  that  we  are  able  to  form  beforehand  an  approx- 


THE  X-RAYS  565 

imate  estimate  of  the  total  number  of  rays  (expressed  in 
H  units)  which  the  skin  will  have  to  absorb  in  order  to 
effect  a  cure.  The  question  then  arises,  Shall  this  amount 
be  administered  in  one  sitting?  If  not,  in  how  many 
sittings  and  at  what  intervals  ?  If  the  total  amount  called 
for  is  less  than  will  excite  erythema,  it  may  be  given  at  one 
sitting.  Thus,  Sabouraud  treats  tinea  tonsurans,  and,  it  is 
said,  usually  effects  a  cure,  at  one  sitting.  The  dose  needed 
here  is  one  which  will  produce  epilation  without  redness, 
4  or  5  H. 

In  the  case  of  neoplasms,  however,  the  matter  is  not  so 
simple.  Here  the  total  amount  required  would,  at  one 
sitting,  produce  severe  dermatitis  and  ulceration.  Evidently 
we  must  use  "  broken  doses"  and  give  at  each  sitting  an 
amount  short  of  what  will  produce  a  reaction.  The  inter- 
val should  be  sufficient  to  allow  the  normal  tissues  to  recover 
their  integrity.  Belot  says:  "We  are  of  the  opinion  that 
the  exposure  should  be  continued  in  spite  of  reaction,  in 
the  treatment  of  lesions  such  as  epithelioma  and  sarcoma, 
in  which  the  rays  may  be  supposed  to  have  an  eliminating 
action.  A  certain  degree  of  erythema,  or  even  a  slight 
inflammatory  reaction,  is  of  advantage  in  such  cases." 

The  same  writer  fixes  the  maximum  total  dose  at  10  H 
per  month ;  others  place  it  at  16  H. 

According  to  Holzknecht,  the  doses  for  single  sittings  are 
as  follows : 

To  produce  epilation  without  redness  of  the  healthy  skin 
of  the  face,  for  young  subjects  3  H,  for  adults  4  H. 

To  set  up  a  reaction  of  the  second  degree,  superficial 
erosion  without  ulceration  or  subsequent  scarring,  5  to  7  H. 

On  flexor  surfaces  of  joints,  to  produce  reaction  of  the 
first  degree,  4  to  6  H,  and  of  the  second  degree,  6  to  8  H. 

For  extensor  surfaces  of  joints,  the  trunk,  scalp,  palms, 
and  soles:  for  the  first  degree  5  to  7  H,  and  for  the  second 
7  to  14  H. 

Where  the  skin  is  already  inflamed  from  any  cause,  a 
reduction  of  1  or  2  H  should  be  made  for  a  dose  of  G  H, 
and  for  a  larger  dose  a  reduction  of  2  or  3  H. 


566    GENERAL  TREATMENT  AND  METHODS 

These  and  all  similar  set  rules  necessarily  proceed  on 
the  assumption  that  all  skins  respond  alike,  or  that 
idiosyncrasy,  if  it  exist,  is  a  negligible  quantity.  This  as- 
sumption is  rejected  by  most  American  therapeutists,  who, 
in  the  interests  of  safety,  use  much  smaller  doses  than 
these  figures  would  indicate,  dividing  each  dose,  as  given 
above,  into  several  sittings.  The  effect  is  not  the  same, 
as  the  tissues  tend  to  return  to  their  former  condition 
between  times.  Beck,  however,  is  bolder,  and  after  three 
tentative  five-minute  sittings,  one  week  apart,  proceeds  to 
ten,  twenty,  or  even  forty-five-minute  sittings  repeated 
every  other  day,  in  obstinate  cases  even  daily.  The  risk 
is  great. 

At  the  Broca  Hospital,  Paris,  Belot  gives  the  required 
dose  at  one  sitting,  or  on  two  consecutive  days.  In  the  sec- 
ond case  the  two  sittings  would  be  considered  as  one  dose. 
The  object  of  dividing  the  dose  into  two  such  parts  is  not 
to  lessen  the  reaction,  for,  indeed,  it  would  have  no  such 
effect,  but  to  spare  the  patient  the  fatigue  of  too  prolonged 
a  sitting.  By  the  required  dose  is  meant  that  dose  which 
will  either  (1)  be  sufficient  to  cure,  or  (2)  when  (as  in 
malignant  neoplasms)  such  an  amount  is  greater  than  the 
tissues  will  bear,  the  largest  safe  dose.  Naturally,  when 
such  large  doses  are  given,  the  interval  is  made  longer  than 
is  usual  on  this  side  of  the  Altantic.  Thus,  Belot  allows 
ten  to  fifteen  days  to  elapse,  and  in  cases  requiring  very 
heavy  doses,  as  in  breast  cancer,  twenty  days.  Be"clere 
generally  waits  a  week. 

Kienbock  employs  maximum  illumination  of  a  moder- 
ately soft  tube.  If  the  lesion  be  small  he  places  the  tube 
very  close.  Of  course,  the  time  is  correspondingly  short. 

He  fixes  upon  a  certain  standard  or  "normal"  exposure. 
By  this  he  means  a  twenty-minute  sitting  with  a  medium 
soft  tube  at  15  to  20  cm.  from  the  surface,  emitting  such  rays 
as  will  give  a  good  fluoroscopic  image  of  the  thorax  at  60 
cm.  from  the  focus,  and  a  radiograph  in  thirty  seconds. 
Such  a  "normal"  exposure  may  be  divided  into  several 
sittings. 


THE  X-RAYS  567 

He  makes  little  change  in  the  quality  or  quantity  of  the 
rays,  frequency  of  interruption,  or  tube  distance,  but 
relies  almost  altogether  on  the  time  element  to  regulate  his 
results,  the  range  being  from  five  to  fifteen  minutes,  about 
|  H  being  absorbed  per  minute. 

Oudin  uses  a  tube  so  soft  as  to  give  a  parallel  spark  of 
2  to  5  cm. ;  heats  the  anticathode  to  a  deep,  cherry  tint,  and 
brings  the  tube  as  near  as  will  permit  of  the  whole  surface 
being  treated  and  will  just  prevent  sparking  over  to  the 
skin.  This  may  be  as  close  as  5  and  will  rarely  exceed 
10  cm.  (2  to  4  inches).  The  exposure  is  consequently 
very  brief  and  should  never  exceed  five  minutes.  He 
begins  with  one-half  minute,  two  days  later  he  gives  one- 
half  minute  more,  and  so  continues  on  alternate  days, 
adding  one-half  minute  each  time  until  three  minutes  is 
reached.  Then  a  week's  interval  is  allowed,  after  which, 
in  the  absence  of  reaction,  the  same  plan  is  followed, 
beginning  with  three  minutes  and  increasing  to  a  fixed 
maximum  of  five. 

Belot's  classification  of  methods  may  be  tabulated  as 
follows : 

1.  Short  intervals  continued  until  reaction  or  cure. 
(a)  Doses  weak. 

(6)  Doses  weak  at  first  and  gradually  increased. 
(c)  Doses  medium  at  first  and  gradually  decreased. 

2.  Total  indicated  dose  in  as  short  a  time  as  safety 
permits. 

(a)  Dose  at  one  sitting. 

(6)  Dose  at  several  sittings. 

Most  American  operators  follow  the  method  (1  6)  of 
gradually  increasing  the  dose  at  short  intervals.  While 
many  brilliant  cures  have  been  effected  by  this  plan,  it  is 
none  the  less  open  to  serious  objections,  both  theoretical 
and  practical.  Since  the  period  of  latency  is  often  pro- 
longed, a  continuation  of  treatment  until  reaction  means 
that  the  patient  receives  several  sittings  more  than  are 
required  (at  the  time)  and,  perhaps,  more  than  are  safe. 
There  can  be  little  doubt  of  the  cumulative  action  of  the 


568    GENERAL  TREATMENT  AND  METHODS 

rays,  so  that  by  the  time  a  mild  erythema  declares  itself, 
the  occurrence  of  severe  ulceration  may  already  have  been 
ensured.  It  is  true  that  by  using  small  doses  at,  relatively, 
long  intervals,  this  danger  is  reduced  to  a  minimum,  but 
this  means  a  great  waste  of  time  and  trouble.  The  method 
is  open  to  the  charge  of  being  inexact  and  unscientific. 
It  is,  nevertheless,  the  method  of  choice  for  allaying  sub- 
jective symptoms.  We  must  admit  that  it  has  the  sanction 
of  some  of  the  best  authorities.  Thus,  Morton  gives  three 
seances  a  week,  of  six  or  eight  minutes;  Williams,  two 
or  three  of  from  five  to  twenty  minutes,  with  the  tube  at 
from  six  to  eight  inches.  Stelwagon  at  first  gives  two 
sittings  a  week,  of  five  minutes  each,  with  the  tube  at  ten 
or  twelve  inches.  If  after  two  weeks,  there  be  no  reaction 
or  improvement,  he  increases  the  exposures  to  three  a 
week,  each  of  ten  minutes.  The  distance,  in  case  of  a 
negative  result,  is  further  reduced  to  eight  and,  finally,  five 
inches.  If  there  be  still  no  effect  the  time  is  increased  to 
fifteen  or  twenty  minutes. 

Pusey  uses  a  medium  light  and  begins  with  exposures  at 
15  cm.  from  the  surface  to  the  wall  of  the  tube.  The  dis- 
tance is  gradually  reduced,  so  that  after  two  weeks  of  daily 
sittings  the  tube  is  at  5  to  8  cm.  The  time  is  then  increased 
so  that  by  two  weeks  more  it  extends  to  fifteen  minutes, 
which  is  his  maximum.  In  case  of  urgent  need  he  con- 
tinues treatment  in  spite  of  moderate  dermatitis,  and  even, 
in  rare  instances,  of  acute,  weeping  dermatitis. 

The  method  of  decreasing  dose  (1  c)  is  followed  by  many 
Europeans,  such  as  Freund,  Scholtz,  Torok,  Gassmann,  and 
others.  The  methods  falling  into  the  second  group  are 
more  exact.  Where  the  estimated  total  dose  is  more  than 
is  compatible  with  the  integrity  of  the  tissues,  it  is  admin- 
istered in  fractions,  so  as  to  keep  within  safe  limits. 

Is  the  Production  of  a  Dermatitis  Necessary? — Most 
practitioners  will,  we  believe,  answer  this  question  in  the 
affirmative.  Most  would,  however,  agree  that  the  der- 
matitis is  not  in  itself  curative,  but  serves  as  an  index  to 
the  fact  that  a  full  dose  (for  the  time)  has  been  received. 


THE  X-RAYS  569 

Freund  and  Scholtz  advocate  short  and  frequent  expo- 
sures repeated  until  a  reaction  is  obtained.  Kienbock  is  of 
the  same  opinion.  According  to  him  some  affections  of 
the  skin  are  curable  by  a  radiodermatitis  of  the  second 
degree,  producible  by  the  absorption  of  4  H,  in  one 
sitting  of  eight  minutes.  Other  diseases  require  an  acute 
dermatitis  repeated  every  two  months.  In  still  other  con- 
ditions he  avoids  an  acute  reaction,  but  endeavors  to  elicit 
a  slow,  chronic  dermatitis,  brought  about  by  exposures  of 
medium  intensity,  once  a  week.  In  still  others,  slight 
reactions  repeated  every  two  weeks  are  sufficient. 

Morton  does  not  cease  treatment  with  the  first  appear- 
ance of  reaction,  but  continues  until  the  initial  erythema 
deepens  into  a  deep-red  or  dark-tan  color.  Once  this 
tanning  has  been  obtained,  the  skin  can  stand  a  much 
heavier  dose  without  suffering  damage. 

Williams  seeks  to  produce  a  slight  dermatitis  or  pig- 
mentation in  malignant  cases,  but  avoids  it  in  benign 
conditions. 

Stelwagon  increases  the  length  of  sittings  and  dimin- 
ishes the  distance  until  he  obtains  improvement  or  a  slight 
reaction. 

Oudin  systematically  endeavors  to  produce  an  erythema 
and  makes  it  the  basis  of  his  treatment,  regulating  the 
duration  of  exposures  and  intervals  in  accordance  therewith. 

Beclere  seeks  to  avoid  a  dermatitis,  except  in  the  gravest 
neoplasms.  His  rule  is  to  give  as  large  an  amount  at  a 
sitting,  and  to  make  the  intervals  as  brief,  as  will  fall  just 
short  of  this  result.  This  means,  in  his  experience,  one 
sitting  a  week. 

If,  however,  we  hold  that  the  one  and  only  essential 
factor  is  the  total  number  of  rays  absorbed,  we  will  agree 
with  Belot  when  he  says,  "Radiodermatitis  is  not  necessary 
for  a  cure.  It  is  most  often  an  accidental  complication, 
sometimes  a  foreseen  result,  but  very  seldom  a  desired 
effect." 

Effects  of  the  Rays  on  Tissues. — As  with  other  thera- 
peutic agents,  so  with  the  x-rays,  the  effects  produced  vary 


570    GENERAL  TREATMENT  AND  METHODS 

with  the  dosage.  A  weak  therapeutic  dose  produces  a 
stimulation  of  normal-tissue  elements,  or,  at  all  events,  of 
epithelial  cells,  evidenced,  for  example,  by  increased  hair- 
growth.  Larger  or  frequently  repeated  doses  cause  a 
degenerative  change  (from  overstimulation  ?)  of  these 
same  elements,  which  is  more  marked  as  these  are  more 
highly  specialized.  Thus,  we  have  arrest  of  proliferation 
at  the  hair  papilla,  shrinking  and  separation  from  the  bulb, 
and  shedding  of  the  hair.  A  long  continuance  or  frequent 
repetition  of  the  process  will  cause  permanent  atrophy  of 
various  structures  of  the  skin,  apparent  through  irreme- 
diable alopecia,  general  thinning  and  wrinkling  of  the 
irradiated  surface,  and  an  appearance  closely  simulating 
that  of  old  age.  This  condition  may  supervene  even  when 
there  has  been  no  dermatitis.  The  absorption  of  rays,  in 
sufficient  amount,  will  elicit  the  phenomena  of  inflammation ; 
these  may  be  limited  to  erythema,  a  flush  resembling  that 
produced  by  sunburn,  disappearing  in  a  day  or  so  without 
visible  trace,  or,  if  of  higher  grade  or  longer  continued, 
accompanied  by  sensations  of  itching  or  burning,  followed 
by  scaling  and  tanning,  or  freckling.  Telangiectases  may 
develop,  or  a  growth  of  downy  hair.  This  constitutes  the 
first  degree  of  dermatitis.  The  second  degree  is  char- 
acterized by  the  formation  of  vesicles  or  blebs  and  swell- 
ing of  the  parts,  with  much  pain,  healing  commencing 
under  favorable  conditions,  ordinarily  in  about  two  weeks. 
In  other  cases  the  inflammation  may  continue  for  months, 
with  here  and  there  abortive  attempts  at  repair,  and  upon 
final  healing  leave  the  skin  smooth,  devoid  of  pigment, 
hairless,  and  very  sensitive.  The  third  degree  is  that  in 
which  there  is  destruction  of  tissue  and  sloughing.  This 
may  be  superficial,  presenting  a  thin,  necrotic  layer  like 
a  diphtheritic  membrane,  while  in  other  cases  it  involves 
not  only  the  entire  thickness  of  the  skin,  but  deep  under- 
lying structures.  The  "Rontgen  ulcer,"  thus  caused,  is 
the  gravest  danger  attending  radiotherapy.  It  is  often 
intensely  painful,  it  discharges  little,  presents  a  grayish  or 
brown  floor,  with  tough,  dry  edges,  and  is  most  intractable 


THE  X-RAYS  571 

to  treatment,  some  cases  persisting  for  a  number  of  years 
in  spite  of  c.ontinuous  treatment.  The  milder  grades  of 
dermatitis  show  the  tissue  changes  common  to  inflam- 
matory processes  of  corresponding  severity,  while  those 
attended  with  deep  destruction  reveal  obliterating  pro- 
liferation of  the  vascular  walls,  thus  explaining  the  inco- 
ercible  nature  of  the  affection.  Deeper  connective  tissue, 
muscle,  and  cartilage  are  but  little  affected,  although  the 
bones,  as,  for  instance,  those  of  the  metacarpus,  may  show 
thickening.  Sometimes  a  first  transitory  erythema  appears 
within  a  few  hours  and  disappears  in  a  day  or  less,  to  be 
followed  a  week  or  so  later  by  a  more  active  process. 

The  skin  is  affected  by  the  rays  more  readily  than  are  the 
deeper  tissues,  not  only  because  it  is  the  first  to  receive 
their  impact,  but  because  it  is  by  nature  more  susceptible. 
This  is  shown  by  the  occasional  occurrence  of  reaction  at 
the  point  of  emergence  of  the  rays  as  well  as  at  their  point 
of  entry,  the  intervening  tissues  remaining  unaffected. 

The  phenomena  of  reaction  resulting  from  the  long- 
continued  repetition  of  small  doses  are  not  the  same  as 
those  observed  after  a  single,  large  dose,  or  several  such 
given  at  short  intervals.  The  former  present  the  characters 
of  acute  inflammation,  while  the  latter,  oftenest  seen  on  the 
persons  of  operators,  are  chronic  or  degenerative.  The 
hand  is  most  frequently  affected.  In  some  cases  the  first 
symptom  is  a  fall  of  hair,  while  in  others  there  is  capillary 
paresis,  the  fingers  becoming  dark  red  or  bluish,  and  their 
integument  dry  and  coarse. 

Later  the  skin  becomes  glossy,  atrophic,  and  wrinkled, 
or  in  other  cases  thickened,  stiffened,  cracked,  and  pig- 
mented.  The  condition  is  sometimes  like  that  in  xeroder- 
ma  pigmentosum,  showing  erythematous  spots,  freckles, 
scaling,  telangiectases,  keratomata,  and,  finally,  in  some 
cases,  epithelioma.  The  nails  are  usually  fissured  and 
striated,  or  may  be  altogether  lost. 

The  cumulative  action  of  the  rays  is  well  marked.  Reac- 
tion will  follow  a  series  of  exposures,  no  one  of  which  could 
have  had  this  result,  even  when  they  are  separated  by  an 


572         GENERAL  TREATMENT  AND  METHODS 

interval  sufficient  to  allow  subsidence  of  all  phenomena. 
A  fact  of  similar  significance  is  that  dermatitis  is  long 
afterward  easily  excited  on  a  surface  once  so  affected.  A 
curious  and  hitherto  unexplained  characteristic  of  radio- 
dermatitis  is  its  period  of  incubation  or  latency.  In  a 
general  way  this  varies  in  length  inversely  as  the  severity 
of  the  exposure.  Sometimes  showing  itself  in  twenty-four 
hours  or  less,  the  dermatitis  is  often  delayed  for  a  week, 
reaching  its  maximum  one  or  several  weeks  later.  The 
great  majority  of  cases  are  apparent  within  a  fortnight, 
although  numerous  instances  of  much  longer  latency  have 
been  reported.  Oudin  mentions  one  of  five  months,  ulcer- 
ation  lasting  a  year,  and  one  of  ten  months,  which  in  the 
next  sixty  days  ran  through  all  the  stages  of  vesiculation, 
ulceration,  and  sloughing.  One  of  us  observed  a  dermatitis 
of  the  second  degree  about  the  face,  accompanied  by  severe 
general  symptoms,  and  diagnosticated  by  a  competent 
physician  as  erysipelas,  which  came  on  four  months  after 
the  last  raying.  It  healed  kindly,  but  recurred  two  months 
later  without  there  having  been  any  further  exposure  to  the 
ray.  In  3  cases  observed  by  Pusey,  relapse  occurred  after 
the  same  interval  of  time.  Atrophy  and  telangiectases  may 
be  delayed  a  year  or  eighteen  months.  A  fact,  analogous  to 
the  latency  of  dermatitis  and  equally  obscure,  is  the  occa- 
sional first  evidence  of  improvement  in  neoplasms  weeks 
or  months  after  suspension  of  treatment. 

Blondes  are  more  subject  to  the  influence  of  the  rays 
than  brunettes,  as  they  are  to  other  forms  of  radiant  energy. 
This  difference  is  easily  accounted  for  by  the  fact  that  the 
pigment  of  the  skin  occludes  a  portion  of  the  rays.  Chil- 
dren are  more  susceptible  than  adults.  That  certain 
regions  of  the  body  are  more  so  than  others  is  affirmed  by 
Holzknecht,  but  denied  by  Pusey  (see  p.  565).  There  also 
exists,  in  certain  individuals,  a  special  susceptibility  for 
which  no  cause  can  be  assigned,  and  which  is  spoken  of 
as  idiosyncrasy.  This  is  strenuously  denied  by  some.1 

1  See  MacLeod,  British  Journal  of  Dermatology,  1903,  p.  365,  for  an 
excellent  review  of  the  pathological  action  of  z-rays. 


THE  X-RAYS  573 

This  question  of  the  existence  of  an  idiosyncrasy  is  one 
of  great  practical  importance.  If  we  hold  with  Kienbock, 
that  "  individuals  in  good  health  react  in  precisely  a  similar 
manner  to  ar-radiance,"  we  must  logically  accept  his  hard 
and  fast  rules  for  dosage.  If,  on  the  other  hand,  we  agree 
with  Pusey  that  "there  is  no  evidence  to  justify  such  a 
statement,"  we  shall,  like  him,  adopt  a  far  more  cautious 
technique.  To  our  minds  the  facts  all  support  the  latter 
contention. 

Dermatitis  is  occasionally  accompanied  by  constitutional 
symptoms,  such  as  headache,  lassitude,  nausea,  and  some 
elevation  of  temperature.  Marked  effects  on  other  and 
deeper  tissues,  such  as  blindness,  abortion,  and  paralysis, 
have  been  experimentally  produced  on  small  animals.  Such 
effects  have  not  been  noted  on  the  human  subject.  The 
relative  immunity  of  the  human  eye  is  indeed  remarkable, 
as,  for  instance,  where  a  dermatitis  of  the  lids  with  vesicu- 
lation  has  occurred  without  injury  to  the  organ  beneath. 
So  with  the  central  nervous  system.  One  of  us  had  the 
opportunity  of  subjecting  this  matter  to  a  thorough  test. 
A  young  man  presented  a  circular  aperture,  four  inches  in 
diameter,  at  the  vertex  of  the  cranium,  due  to  a  deep  burn 
in  infancy.  The  brain  within  this  area  was  devoid  of  other 
protection  than  its  membranes  and  a  layer  of  scar  tissue. 
Within  this  scar  there  developed  a  carcinoma,  which  when 
first  seen  overlapped  the  bony  defect  at  all  points.  This 
was  subjected  for  weeks  to  daily  quarter-hour  raying  from 
a  powerful  tube,  with  the  anticathode  perpendicular  to  the 
centre  at  a  distance  of  six  and  one-half  inches.  At  no  time 
was  any  effect  on  the  cerebrum  discernible. 

There  is  no  question,  however,  of  the  sedative  effect  of 
the  rays  on  peripheral  nerves. 

Before  leaving  the  subject  of  the  mode  of  action  of  the 
rays  we  may  ask  whether  they  are  bactericidal.  This 
question  has  received  both  positive  and  negative  answers. 
The  truth  seems  to  be,  that,  whereas  destruction  of  low 
forms  of  organic  life,  or  an  arrest  of  their  growth,  may  be 
experimentally  obtained  in.the  laboratory  by  massive  doses 


574    GENERAL  TREATMENT  AND  METHODS 

of  the  rays,  no  such  effect  can  be  obtained  within  safe  thera- 
peutic limits.  It  should  be  mentioned,  however,  that  Pusey, 
one  of  the  best  American  radiotherapeutists,  still  holds  to 
a  bactericidal  effect  therapeutically  obtainable. 

For  the  treatment  of  radiodennatitis,  see  p.  186. 

In  the  earlier  portions  of  this  work,  the  indications  are 
given  for  the  use  of  the  x-rays  in  the  following  diseases : 

Acne  rosacea,  acne  varioliformis,  acne  vulgaris,  actino- 
mycosis,  alopecia,  alopecia  areata,  angioma,  blastomycosis, 
caHositas,  carcinoma,  cicatrix,  clavus,  comedo,  cornu,  der- 
matitis papillaris  maligna,  eczema,  eczema  seborrhoicum, 
epithelioma,  epithelioma  multiplex  benign um  cysticum, 
favus,  herpes  zoster,  hyperidrosis,  hypertrichosis,  ichthyo- 
sis,  keloid,  keratoderma  palmaris  et  plantaris,  keratosis 
follicularis,  keratosis  senilis,  lepra,  leucoplakia,  lichen 
planus,  lupus  erythematosus,  mycosis  fungoides,  nsevus 
pilosus,  parapsoriasis,  prurigo,  pruritus,  psoriasis,  rhino- 
scleroma,  sarcoma,  scleroderma,  scrofuloderma,  tinea 
tonsurans,  tinea  barbse,  tuberculosis  disseminata,  tubercu- 
losis ulcerosa,  tuberculosis  verrucosa,  ulcus,  urticaria 
pigmentosa,  verruca  necrogenica,  verruca  vulgaris,  vitiligo, 
xanthoma,  and  xeroderma  pigmentosum. 


RADIUM. 

The  year  following  Rontgen's  discovery,  Becquerel 
found  that  uranium  and  its  salts  spontaneously  gave  off 
certain  rays  which  possessed  the  properties  of  (1)  acting  on 
a  photographic  plate;  (2)  exciting  phosphorescence,  and 
(3)  ionizing  the  air  (making  it  a  conductor).  Substances 
giving  off  such  rays  are  said  to  be  radio-active,  and  the  rays 
are  known  as  Becquerel  rays. 

Uranium  occurs  chiefly  as  an  oxide  in  pitch-blende. 
From  some  tons  of  this  mineral,  M.  and  Mme.  Curie 
obtained  a  few  decigrams  of  a  salt  of  an  element  which  they 
called  radium.  Its  radio-activity  is  about  one  million  times 
that  of  uranium. 


RADIUM  575 

Radio-active  substances  give  off  three  forms  of  energy, 
designated  as  a,  ft  and  ?  rays.  The  first  of  these  exert 
almost  the  whole  ionizing  power,  but  are  otherwise  feeble. 
The  second  are  very  similar  to,  and  possibly  identical 
with,  cathode  rays.  The  third  closely  imitate  x-rays. 
Radium  also  gives  off  gaseous  substances  called  emanations. 
They  are  themselves  radio-active,  and  impart  this  property 
to  solid  substances  with  which  they  come  in  contact. 

Radium  is  a  spontaneous  source  of  heat,  light,  and  elec- 
tricity. 

As  metallic  radium  is  unstable  in  the  air,  only  the  chloride 
and  bromide  are  available  for  use.  In  practice  these  are 
often  diluted  with  other  salts,  such  as  barium  chloride. 
These  exist  in  varying  proportions  in  the  specimens  sold  for 
therapeutic  use.  Their  radio-activity  is  expressed  as  so 
many  times  that  of  uranium,  and  is  estimated  by  the  ra- 
pidity with  which  they  discharge  a  gold-leaf  electroscope, 
the  standard  unit  of  time  being  that  required  for  the  dis- 
charge of  the  electroscope  by  metallic  uranium.  Accord- 
ing to  Allen  (1904)  specimens  offered  on  the  American 
market  vary  in  radio-activity  from  1000  to  300,000.  Pure 
radium  bromide  registers  as  high  as  1,800,000.  Williams 
says  that  this  is  none  too  strong. 

It  was  soon  found  that  carrying  radium  about  the  person 
resulted  in  dermatitis,  sometimes  of  a  severe  character. 
Three  grades  of  burn  are  recognized,  virtually  identical 
with  the  three  grades  of  x-ray  dermatitis. 

The  method  of  application  is  simple.  The  salt  may  be 
enclosed  in  a  box  or  capsule  of  aluminum,  or  in  a  glass  tube, 
and  bound  to  the  part,  or  placed  at  a  certain  distance  if  a 
weaker  action  is  desired.  For  still  weaker  effects  it  may  be 
diluted  with  some  inert  substance,  such  as  barium  chloride, 
and  enclosed  in  a  caoutchouc  bag. 

Strassmann  has  used  this  agent  with  complete  or  partial 
success  in  lupus  erythematosus  (3  cases),  lichen  planus, 
rosacea,  and  vascular  nevus.  For  its  use  in  epithelioma 
and  other  affections,  see  Part  I. 


576         GENERAL  TREATMENT  AND  METHODS 


PHOTOTHERAPY. 

The  therapeutic  value  of  the  rays  of  the  sun  were  known 
before  Malachi  spoke  of  his  rising  "with  healing  in  his 
wings."  Their  effect  was  ascribed  wholly  to  the  heat  and 
light  conveyed,  until  toward  the  end  of  the  eighteenth 
century,  when  Scheele  and  others  showed  the  existence  of 
chemical  rays  capable  of  reducing  silver  salts.  In  1801 
Hitter  showed  the  existence  of  heat  rays  below  the  red  end 
of  the  spectrum  and  chemical  rays  above  the  violet.  Soon 
after  the  introduction  of  the  electric  arc  light  there  were 
observed  effects  upon  the  skin  similar  to  sunburn.  These 
were  shown  by  Charcot  to  be  due  to  the  chemical  rays 
which  this  light  contains  in  even  greater  abundance  pro- 
portionately than  that  of  the  sun.  Various  attempts  were 
made  to  utilize  these  rays  in  the  treatment  of  disease, 
but  nothing  was  accomplished  in  a  systematic  or  rigidly 
scientific  way  until  the  researches  of  Niels  Finsen,  of 
Copenhagen,  whose  early  loss  the  world  still  mourns. 

Phototherapy  is  either  positive  or  negative.  In  the 
former  the  chemical  rays  are  selected  and  concentrated 
upon  the  region  to  be  influenced.  In  the  latter  these  rays 
are  excluded.  In  this  way  an  inflamed  surface  may  be 
spared  undesirable  stimulation. 

The  light  spectrum  is  overlapped  by  the  heat  spectrum 
at  its  lower  or  red  end,  and  by  the  chemical  spectrum  at  its 
upper  or  violet  end.  Thus  by  shutting  out  all  the  rays 
above  the  orange  we  can  exclude  the  chemical  spectrum, 
and  by  shutting  out  all  below  the  blue  eliminate  nearly  all 
the  heat.  Violet  light,  as  a  matter  of  course,  contains  no 
more  active  rays  than  does  white  light,  since  white  light 
contains  all,  but  the  light  rays  below  the  blue  are  accom- 
panied with  so  few  chemical  rays  as  to  be  worthless  for 
therapy,  while  the  admission  of  the  large  number  of  heat 
rays,  from  the  yellow  to  the  red,  and  below,  would  make  the 
method  impracticable.  The  chemical  rays  accompanying 
blue  light  are  fewer  than  those  in  the  violet  and  ultraviolet, 


PHOTOTHERAPY  577 

but  more  penetrating.  Penetration  increases  through 
green,  yellow,  and  orange,  and  is  greatest  in  the  red.  Bie 
showed  that  the  bactericidal  power  of  light  extends 
throughout  the  spectrum,  although  only  4  per  cent,  of  it  is 
in  the  red,  yellow,  and  green,  the  other  96  per  cent,  being 
exercised  in  the  blue,  violet,  and  ultraviolet. 

Negative  phototherapy  was  advised  by  Finsen  in  the 
treatment  of  smallpox.  His  premises  are:  first,  that  the 
distress  and  peril  of  the  patient  vary  directly  as  the  amount 
of  suppuration;  and,  second,  that  the  amount  of  suppura- 
tion varies  directly  as  the  number  of  chemical  rays  which 
reach  the  skin.  Accordingly  none  but  red  light  is  allowed  to 
enter  the  sick-room.  The  method  should  be  rigidly  applied 
in  order  to  obtain  the  results  claimed  by  Finsen,  namely, 
the  elimination  of  suppuration  and,  therefore,  of  the  fever 
of  suppuration.  The  patient  should  be  introduced  into 
the  red-room  from  the  first  appearance  of  the  eruption. 
The  room  should  be  as  carefully  guarded  from  all  but  red 
light  as  is  a  photographer's  developing  room. 

Finsen  considered  that  the  method  was  imperfectly 
applied  if  an  exposed  sensitized  plate  showed  blurring.  The 
method  thus  strictly  applied  gave  good  results  in  his  hands. 
It  has  been  employed  in  measles  and  erysipelas  as  well. 

Positive  Phototherapy.  Apparatus. — Besides  the  lamp 
designed  by  Finsen  and  used  at  the  Lysinstitut,  a  host  of 
modifications  and  imitations  have  come  into  existence,  the 
best  of  which  are  decidedly  inferior  to  Finsen's  model, 
while  many  are  absolutely  useless  and  constructed  in 
defiance  of  scientific  laws.  We  deprecate  the  looseness  with 
which  some  writers  speak  of  their  results  with  the  "  Finsen 
treatment"  when  they  have,  perhaps,  never  come  within  a 
thousand  miles  of  a  Finsen  lamp. 

Finsen's  apparatus  consists  of  an  80-ampere,  50-volt  arc 
light  enclosed  in  a  circular  box  some  six  or  seven  feet  above 
the  floor.  From  this  box  four  telescopic  tubes  radiate  down- 
ward and  outward.  In  each  tube  are  several  condensing 
lenses,  7  cm.  in  diameter,  for  the  purpose  of  concentrating 
the  rays  and  thus  ensuring  their  deep  penetration.  Inas- 
37 


578    GENERAL  TREATMENT  AND  METHODS  , 

much  as  glass  is  opaque  to  ultraviolet  rays,  the  lenses  are 
all  made  of  rock-crystal  or  quartz.  As  the  lower  end  of  the 
spectrum  is  not  excluded,  it  is  necessary  to  provide  for  the 
absorption  of  heat.  This  is  secured  by  filling  a  section  of 
the  tube  between  two  lenses  with  distilled  water.  Besides 
this,  the  tube  is  surrounded  by  a  hollow  jacket  in  which 
ordinary  water  circulates.  The  patient  lies  upon  a  couch 
with  the  part  to  be  treated  six  or  seven  inches  below  the 
lower  end  of  the  tube.  An  additional  detached  condenser 
consisting  of  two  lenses  united  by  a  circular  metal  band, 
while  an  in-and-out  flow  permits  the  circulation  of  water 
between  them,  is  firmly  attached  to  the  affected  surface 
and  further  maintained  in  place  by  an  attendant.  This 
additional  condenser  serves  the  double  purpose  of  further 
absorbing  the  heat  rays  and  by  compression  driving  the 
blood  from  the  part,  facilitating  penetration.  A  solution 
of  copper  sulphate  was  formerly  used  in  the  tube  instead  of 
distilled  water.  An  area  one-half  to  one  inch  in  diameter 
may  be  treated  at  a  time.  An  ordinary  sitting  lasts  an  hour, 
with  the  extremes  at  one-half  and  twice  that  length  of  time. 

The  Finsen-Reyn  lamp,  used  at  the  same  institution,  is  a 
smaller  model  operated  with  a  20-ampere  arc,  and  is  prac- 
tically the  same  thing  except  in  its  lower  power  and  the 
mechanical  details  of  its  construction.  Instead  of  being 
suspended  from  the  ceiling,  the  apparatus  is  secured  to  a 
standard  mounted  upon  a  heavy  base.  But  one  patient 
can  be  treated  at  a  time. 

Another  type,  which  includes  the  Lortet  and  Genoud 
and  the  London  Hospital  lamps,  discards  the  telescopic 
condensing  lenses  and  brings  the  arc  light  as  close  as  two 
inches  from  the  patient.  Between  them  is  interposed  a 
saucer-shaped,  hollow  metallic  shield,  at  the  centre  of  which 
are  fitted  two  lenses  separated  by  an  interval.  Cold  water 
circulates  between  the  lenses  and  within  the  shield.  The 
patient  presses  the  diseased  area  against  the  outer  lens. 
While  this  lamp  brings  about  an  erythema  more  rapidly 
than  does  Finsen's  model,  it  is  deficient  in  penetrating 
rays,  and,  therefore,  far  less  efficient. 


PHOTOTHERAPY  579 

The  Bang  lamp,  which  has  water-cooled,  hollow-iron 
electrodes  furnishing  abundant  ultraviolet  rays,  also  pro- 
duces a  rapid  surface  effect,  but  is  even  poorer  than  the 
last  in  deep  rays.  The  Dermo  lamp  is  a  modification  of 
Bang's.  Piffard  and  others,  inspired  by  the  exceeding 
richness  of  the  electric  spark  in  ultraviolet  rays,  have  con- 
structed small  lamps  in  which  sparks  pass  between  four 
or  five  close-set  metallic  knobs.  The  apparatus  is  to  be 
held  close  against  the  skin.  The  action  is  very  superficial. 

The  mercury-vapor  lamp,  originated  by  the  German 
electrician  Aarons,  and  improved  by  Hewitt,  of  New  York, 
emit  few  or  no  red  rays,  but  is  exceedingly  rich  in  the 
blue,  violet,  and  ultraviolet.  The  latter,  however,  are 
largely  absorbed  by  the  glass  of  the  tube.  Schott  makes 
a  glass,  believed  to  be  of  barium-phosphate-chrome,  which 
is  pervious  to  the  chemical  rays.  This  he  employs  in  the 
"uviol"  lamp  (contracted  from  ultraviolet).  This  lamp 
has  been  successfully  used  for  some  time  by  various 
German  workers  and  in  this  country  by  Dr.  Schamberg, 
of  Philadelphia.  The  latter  has  found  this  light  to  be  of 
service  in  alopecia  areata,  leg  ulcers,  and  certain  forms 
of  eczema. 

The  various  incandescent  lamp  arrangements  on  the 
market  need  not  be  discussed  in  an  article  on  phototherapy, 
inasmuch  as  this  light  is  very  poor  in  active  rays,  to  which, 
besides,  glass  is  opaque.  A  very  large  incandescent  lamp 
may  be  of  some  use  as  a  source  of  heat.  Of  course  the  use  of 
a  blue  or  violet  globe  only  makes  the  apparatus,  if  possible, 
more  useless.  All  that  the  color  of  a  transparent  medium 
can  do  is  to  subtract  rays.  It  cannot  possibly  add  any- 
thing. But  a  blue  color  in  a  medium  like  water,  trans- 
parent to  chemical  rays,  may  be  of  use  in  absorbing 
excessive  heat  rays. 

Technique. — Finsen  laid  great  stress  on  the  importance 
of  rendering  the  part  exsanguine  by  pres>iin>.  .Jamirson 
substituted  the  application  of  the*  1  to  1000  adrenalin 
chloride  solution.  Piffard  drives  this  solution  into  the 
tissues  by  cataphoresis. 


580    GENERAL  TREATMENT  AND  METHODS 

The  average  sitting  with  the  Finsen  lamp  lasts  one  hour. 
G.  H.  Graham  believes  that  the  action  of  the  light  can  be 
enhanced  by  the  injection  of  fluorescent  bodies  such  as 
esculin. 

Action. — Redness  appears  from  one  to  twenty-four 
hours  after  the  sitting.  Generally  there  is  edema,  exu- 
dation, and  crusting,  sometimes  vesication.  These  subside 
in  a  week  without  leaving  a  scar.  There  is  dilatation 
of  cutaneous  bloodvessels  with  leukocytosis.  Proliferation 
of  blood-vascular  endothelium,  increased  epithelial  mitosis 
and  increase  in  the  number  of  connective-tissue  cells,  with 
swelling  of  the  collagen,  have  been  noted. 

The  beneficial  effects  of  phototherapy  seem  to  depend 
upon  (1)  the  excitement  of  inflammation  which  the  dis- 
eased tissues  are  less  able  to  withstand;  (2)  stimulation 
of  the  surrounding  healthy  tissue;  (3)  destruction  of 
bacteria.  The  last-named  effect  is  quite  well  established. 

Phototherapy  has  been  used  with  benefit  in  acne  vul- 
garis,  acne  rosacea,  alopecia  areata,  epithelioma,  lupus 
erythematosus,  naevus  vasculosus,  vitiligo,  eczema,  chronic 
ulcer,  actinomycosis,  sycosis,  psoriasis,  pruritus,  and  lupus 
vulgaris.  In  the  last-named  disease  it  has  won  its  greatest 
triumphs.  To  the  comparative  rarity  of  this  disease  in 
America  is  due  the  fact  that  the  method  has  never  come 
into  wide  use  here.  Kromayer  reports  startling  results  in 
alopecia  areata,  using  an  iron-electrode  lamp.  Indica- 
tions for  the  use  of  phototherapy  will  be  found  in  the 
articles  on  the  various  diseases  in  Part  I  of  this  work. 


ASEPSIS  AND  ANTISEPSIS. 

The  rigid  rules  of  asepsis  in  the  preparation  of  the  field 
of  operation,  so  necessary  in  major  surgery,  are  rarely 
imperative  in  the  minor  procedures  practised  by  the  der- 
matologist. Thorough  cleanliness  and  swabbing  with  a  1 
to  5000  mercuric  chloride,  or  a  2  per  cent,  carbolic  solution 
are  usually  sufficient.  On  the  other  hand,  all  instruments 


ANESTHESIA  5gj 

should  be  scrupulously  sterilized  and  the  disinfection  of 
the  operator's  hands  practised  as  a  matter  of  routine. 


ANESTHESIA. 

Local  anesthesia,  for  minor  surgical  procedures,  may 
be  obtained  by  freezing,  or  by  the  intradermic  injection  of 
cocaine  or  one  of  its  congeners.  The  methods  by  the  appli- 
cation of  carbolic  acid,  the  high-frequency  current,  etc., 
are  too  unreliable  to  merit  discussion. 

Freezing  Methods. — These  are  virtually  limited  to  the 
ether  and  ethyl  chloride  sprays.  The  first  may  be  applied 
with  an  ordinary  atomizer.  Its  effect  is  obtained  more 
rapidly  by  placing  small  wisps  of  cotton  on  the  skin,  thus 
increasing  the  surface  for  evaporation.  While  efficient, 
it  is  open  to  a  serious  objection  from  the  inflammability 
of  the  agent,  making  its  use  dangerous  in  connection  with 
the  thermocautery.  Ethyl  chloride  is  far  safer  as  well  as 
more  convenient.  It  may  be  had  in  glass  bulbs  furnished 
with  a  vent  controlled  by  a  lever  within  easy  reach  of  the 
operator's  thumb. 

All  freezing  methods  are  open  to  certain  objections.  In 
the  first  place  there  is  some  pain  during  congelation,  but 
usually  more  later,  while  the  region  is  thawing.  At  this 
time,  too,  there  is  some  increase  in  the  tendency  to  hemor- 
rhage. These  matters  are  not  serious,  but  what  is  more 
worthy  of  consideration  is  the  attendant  alteration  in  the 
color  and  hardness  of  the  tissues,  so  that  the  limits  of  the 
lesion  can  no  longer  be  appreciated  by  the  eye  or  hand. 
In  most  work  with  the  curette  this  is  a  fatal  objection,  as 
the  operator  is  generally  chiefly  guided  by  the  degrees  in 
resistance  of  the  tissues.  The  method  is  better  adapted 
for  use  with  the  cautery,  or  when  a  single  incision  is 
required,  as  in  laying  open  a  small  abscess.  In  such  cases 
it  is  well  to  begin  by  outlining  the  area  to  be  operated  on 
with  ink  or  a  dermographic  pencil.  An  ordinary  aniline 
pencil,  moistened,  answers  very  well. 


582         GENERAL  TREATMENT  AND  METHODS 

Endennic  Injection. — Medical  literature  records  many 
fatal  accidents  from  the  use  of  cocaine  for  local  anesthesia, 
while  in  a  far  larger  number  of  cases  there  developed  alarm- 
ing symptoms,  death  being  averted  only  by  the  prompt 
action  of  the  physician.  These  accidents  are  due  (1)  to 
the  use  of  solutions  of  unnecessary  and  dangerous  strength ; 
(2)  to  the  use  of  too  large  a  quantity  of  the  solution;  (3) 
to  the  solution  being  injected  hypodermically  and  not,  as  it 
should  be,  endermically;  (4)  to  the  untoward  condition  of 
the  patient.  We  will  review  these  factors  seriatim. 

1.  Excessive  strength  of  the  solution.    We  believe  that 
the  solutions  generally  used  are  far  stronger  than  need  be. 
The  French  surgeon  Reel  us,  as  long  ago  as  1893,  published 
a  list  of  2000  operations  performed  under  complete  anal- 
gesia, most  of  them  with  a  1  per  cent,  solution  of  cocaine,  and 
in  rare  instances  one  of  2  per  cent.    The  latter  strength  was 
never  exceeded.    In  no  case  were  there  any  bad  symptoms. 

2.  Quantity  of  solution  used.    When  injection  is  carefully 
made  into  the  .corium  and  not  beneath  it,  not  only  is  the 
result  obtained  more  rapidly  and  more  completely,  but, 
what  is  even  more  important,  with  a  much  smaller  quantity. 
Even  so,  however,  diffusion  occurs  into  the  circulation. 
We  should  remember  that  we  are  dealing  with  a  potent 
agent  and  should,  therefore,  accurately  measure  the  dosage. 
It  is  a  good  rule  never  to  take  up  into  the  syringe  more  than 
the  maximum  dose  we  have  determined  to  employ.    The 
minimum  fatal  dose  of  cocaine  to  the  adult  is  certainly  not 
more  than  ^  gr.    This  amount  is  contained  in  8  minims  of 
a  4  per  cent,   solution;   8  minims  of  a  2  per  cent,  solu- 
tion should  be  the  maximum  dose,  to  be  rarely  employed. 

3.  Manner  of  injection.    This  was  mentioned  in  the  last 
paragraph  and  will  be  further  elucidated  below. 

4.  Condition  of  the  patient.    Among  counterindications 
are  organic  or  serious  functional  disease  of  the  heart, 
hysteria,  and  profound  neurasthenia. 

Among  the  toxic  symptoms  of  cocaine  are  pallor,  pro- 
fuse perspiration ;  frequent,  feeble,  irregular,  or  intermittent 
pulse;  unconsciousness,  dizziness,  nausea,  blindness,  deaf- 


ANESTHESIA  533 

ness,  muscular  rigidity,  lividity,  convulsive  or  suspended 
respiration,  and  paralysis.  Upon  the  supervention  of  any 
of  these,  the  patient  should  be  placed  at  once  in  the  full 
recumbent  position,  with  the  head  lower  if  possible  than  the 
rest  of  the  body,  and  restoratives  applied,  such  as  ammonia, 
alcohol,  nitroglycerin,  digitalis,  strychnine,  and  atropine. 
It  may  be  necessary  to  use  artificial  respiration.  As  in 
morphine  poisoning,  it  is  not  safe  to  leave  the  patient  for 
some  time,  even  after  apparent  recovery,  as  a  second  or 
even  a  third  collapse  may  occur. 

The  "infiltration  anesthesia"  of  Schleich  is  a  great 
advance,  inasmuch  as  with  its  use  one  can  keep  entirely 
within  safe  limits,  and  yet  do  all  that  can  be  done  with  the 
stronger  solutions.  For  moderately  hyperesthetic  areas 
Schleich  uses  his  "normal"  solution: 

1$ — Cocainae  hydrochloridi gr.  ij 

Morphinse  hydrochloridi gr.  ss 

Natrii  chloridi  sterilizati gr.  iv 

Aquae  destillatse  sterilizatse  f  5iv 
Adde: 

Acidum  carbolicum gtt.  ij — M. 

For  areas  the  seat  of  inflammation,  neuralgia,  etc.,  he 
uses  a  solution  containing  twice  the  proportion  of  cocaine 
given  above. 

Schleich  insists  that  the  injections  should  be  endermic 
and  not  hypodermic.  Inasmuch  as  we  have  absolutely  no 
right  to  inflict  unnecessary  pain,  we  should  use  only  the 
finest  of  needles,  such  as  those  made  by  Green.  The  punc- 
ture, made  almost  horizontally,  is  not  to  extend  below 
the  corium.  A  blanching  and  slight  swelling  about  the 
point  as  soon  as  pressure  is  made  upon  the  piston,  together 
with  the  resistance  encountered  by  the  latter,  announce  the 
success  of  the  little  maneuver.  The  needle  is  withdrawn 
after  a  few  seconds,  reintroduced  just  within  the  edge  of 
the  blanched  area,  and  a  second  injection  made  just  beyond 
the  first.  By  repeating  this  process,  as  often  as  necessary, 
we  soon  obtain  an  anesthesia  lasting  ten  minutes  or  longer. 
The  patient  need  feel  only  the  first  puncture. 


584         GENERAL  TREATMENT  AND  METHODS 

Of  the  many  substances  brought  forward  as  substitutes 
for  cocaine,  only  one  is  satisfactory,  namely,  eucaine  B, 
probably  the  best  local  analgesic  known  today.  It  is  less 
poisonous  than  cocaine,  less  irritating  to  the  tissues;  its 
solutions  will  keep  longer,  and  may  be  sterilized  by  boiling 
without  change.  Its  anesthetic  power  is  equal  to  that  of 
cocaine  and  lasts  as  long.  Braun,  who  has  done  so  much 
in  this  field,  advises  a  solution  containing  1  part  eucaine  B 
and  8  of  sodium  chloride  to  1000  of  water. 

A  late  analgesic,  alypin,  is  not  properly  a  substitute  for 
cocaine,  but  gives  the  best  results  in  combination  with  it. 
Schleich  uses  for  infiltrations:  1$ — Cocainse,  gr.  ij;  alypin, 
gr.  ij;  sodii  chloridi,  gr.  iv;  aquae  destillatse  fl.,  §iv. 


THE  CURETTE. 

This  little  instrument  occupies  a  wide  field  of  usefulness 
in  dermotherapy,  both  as  employed  alone  and  to  prepare 
the  way  for  other  agents.  In  lupus,  small  epitheliomata, 
molluscum  contagiosum,  and  in  pustular  acne,  its  use  is 
rapid,  easy,  and  efficient.  It  may  be  used  for  the  removal 
of  warts  and  small  papillomata,  although  with  them  not  the 
method  of  election.  The  hand  soon  learns  to  distinguish 
between  the  degrees  of  resistance  offered  by  diseased  tissue 
as  compared  with  normal,  thus  acquiring  an  easy  and  safe 
guide.  The  tissues  should  be  put  lightly  on  the  stretch. 
Several  sizes  and  shapes  of  curettes  should  be  at  hand,  so 
that  the  greater  part  of  a  lesion  may  be  rapidly  removed 
with  a  larger  and  broader  instrument,  and  the  operation 
completed  with  a  smaller  and  narrower  one,  which  will  per- 
mit the  thorough  cleaning  out  of  all  pockets  and  recesses. 
The  minute  instrument  used  by  ophthalmologists  will  some- 
times be  useful  at  the  final  stage.  Ring  and  crescent- 
shaped  curettes  are  better  than  those  with  a  solid  bowl, 
which  may  occasion  delay  by  the  scrapings  packing  into 
the  concavity. 

Curetting  alone  is  sufficient  for  the  removal  of  lesions 


THE  SCARIFIER  535 

showing  little  tendency  to  recurrence.  In  dealing  with 
lupus  and  epithelioma,  on  the  other  hand,  it  is  usually  neces- 
sary to  follow  it  up  with  a  chemical  or  thermocautery.  A 
preliminary  partial  curetting,  before  resorting  to  the  ar-rays, 
may  save  much  time,  especially  in  dealing  with  sclerosed 
lesions. 

The  usually  slight  resulting  hemorrhage  will  generally 
yield  to  a  minute's  compression  with  a  pledget  of  gauze.  If 
it  persist,  adrenalin  chloride,  1  to  1000,  may  be  used.  This 
invaluable  styptic  should  always  be  at  hand.  One  should 
not  forget  the  existence  of  hemophilia.  We  should,  there- 
fore, enquire  as  to  our  patient's  past  experiences  in  the 
matter  of  bleeding,  and  in  suspicious  instances  be  pro- 
vided with  powerful  styptics  such  as  the  perchloride  or 
subsulphate  of  iron,  and  a  thermocautery. 

Rigid  asepsis  of  the  instrument  is  at  all  times  essential. 
Thorough  cleanliness  and  mopping  with  one  of  the  ordinary 
antiseptics  will  suffice  for  the  field  of  operation.  When  an 
anesthetic  is  to  be  used,  cocaine  or  Schleich's  solution  should 
be  preferred  to  any  freezing  method,  as  the  latter  robs  us  of 
the  valuable  guide  furnished  by  the  degree  of  resistance 
of  the  tissues. 

The  choice  of  dressing  after  operation  will  depend  upon 
the  nature  of  the  lesion.  Thus,  a  salicylic  plaster  may  be 
used  after  the  removal  of  warts  or  papillomata,  while 
spirit  of  camphor  is  recommended  in  molluscum  contagi- 
osum.  In  malignant  and  tuberculous  lesions,  after  the  fall 
of  the  eschar  produced  by  the  usual  cauterization,  we  may 
use  ordinary  healing  applications,  such  as  boric  acid,  aristol, 
iodol,  or  europhen. 


THE  SCARIFIER. 

In  dermatology,  the  term  scarification  is  used  in  a  limited 
and  precise  sense  to  denote  a  certain  minor  surgical  pro- 
cedure, which  consists  in  making  a  series  of  close,  parallel 
incisions  into  a  diseased  area,  intersected  at  an  acute  angle 


586         GENERAL  TREATMENT  AND  METHODS 

by  a  similar  series,  so  as  to  leave  a  number  of  minute 
lozenge-shaped  figures.  A  third  and  even  a  fourth  series 
may  cross  these  at  various  angles.  The  method  has  found 
its  chief  application  in  lupus  vulgaris,  but  has  also  been 
employed  with  more  or  less  success  in  lupus  erythematosus, 
the  first  and  second  stages  of  rosacea,  vascular  nevi,  keloid, 
hypertrophied  cicatrix,  and  inveterate  anal  and  vulvar 
pruritus. 

In  lupus,  it  gives  the  best  and  occasionally  brilliant 
results  in  rapidly  destructive  forms;  is  less  efficient  in 
simple  ulcerous  lesions,  and  least  so  in  the  non-exedent 
type.  A  thin-bladed  knife  is  lightly  grasped  so  as  to  permit 
the  hand  to  appreciate  the  varying  degrees  of  resistance 
offered  by  the  tissues,  and  the  incisions  made  as  close  set 
and  as  rapidly  as  possible,  extending  them  a  little  into 
sound  tissue  at  each  end,  and  sinking  just  beyond  the  soft 
lupic  layer.  Several  series  of  cross-sections  should  reduce 
the  tissue  to  a  bloody  pulp.  Strangely  enough,  the  area 
thus  treated  does  not  slough,  but  soon  becomes  reor- 
ganized and  partly  cicatricial.  The  obliteration  of  a  num- 
ber of  capillaries  and  small  vessels  thus  ensured,  so  lowers 
the  nutrition  of  tuberculous  foci  as  to  determine  their 
absorption.  After  waiting  for  healing  and  the  subsidence  of 
reaction,  the  procedure  is  repeated.  This  is  done  several 
or,  it  may  be,  many  times.  A  simple  antiseptic  may  be 
applied  after  the  operation.  Taking  it  for  granted  that  the 
blade  is  perfectly  clean,  we  may  say  that  strict  asepsis  of 
the  field  of  operation  is  not  essential  and  that,  as  a  matter 
of  fact,  sepsis  does  not  occur.  The  cicatrices  obtained  in 
this  way  are  especially  soft  and  smooth. 

In  lupus  erythematosus  the  measure  is  of  doubtful 
utility,  and  may  be  an  infringement  of  the  precept  non  nocere. 
In  rosacea  it  is  better  adapted  to  the  destruction  of  dilated 
and  varicose  venules  than  to  the  earlier  generalized  blush. 
It  is  much  more  formidable  than  electrolysis  and  probably 
affords  no  larger  proportion  of  lasting  cures.  No  marked 
effect  need  be  expected  in  keloid,  although,  according  to 
Brocq,  the  pains  are  thereby  greatly  lessened.  In  vascular 


THE  COMEDO  EXPRESSOR  537 

nevus  the  method  is  inferior  to  electrolysis.    For  its  indi- 
cations in  pruritus,  the  reader  is  referred  to  that  article. 

Balmanno  Squire  devised  a  multiple  scarifier  consisting 
of  a  number  of  parallel  blades.  It  has  never  come  into 
general  use.  It  is,  indeed,  impossible  with  this  instrument 
to  suit  the  depth  of  the  incisions  to  that  of  the  infiltration, 
nor  can  it  be  thoroughly  cleaned. 


THE  CUTANEOUS  PUNCH. 

This  little  implement,  also  known  as  the  cutaneous 
trephine,  devised  by  Watson  and  later  advocated  by  Keyes, 
consists  of  a  small,  steel  cylinder  presenting  a  cutting  edge 
at  one  end  and  open  at  the  other,  mounted  on  a  shank  and 
fitted  to  a  straight  handle.  Various  sizes  range  in  diameter 
from  that  of  a  pin's  head  to  one-third  of  an  inch.  With  it 
small  disks  of  skin  can  be  punched  out,  using  simultaneous 
downward  and  rotary  pressure,  the  little  plug  being  then 
snipped  off  with  small,  curved  scissors.  Its  chief  use  is 
probably  in  the  removal  of  pieces  of  tissues  for  examination, 
although  it  also  finds  a  therapeutic  application  in  tattoo 
marks,  powder  stains,  and  minute  lesions  of  various  sorts. 

Kromayer's  plan  of  driving  the  instrument  by  a  small 
engine  will  never  become  popular.  He  not  only  uses  this 
method  in  those  conditions  to  which  the  hand  punch  is 
applied,  but  employs  it  in  hypertrichosis,  excising  a  small 
cylinder  of  tissue  containing  the  follicle. 


THE  COMEDO  EXPRESSOR. 

The  instruments  named  after  Clover,  Unna,  and  Piffard 
are  virtually  the  same,  the  last  named  possessing  ;i  slight 
advantage  in  its  American  elegance  of  shape  and  con- 
venience. They  consist  of  a  shaft  bearing,  at  each  end, 
a  small  cup  or  spoon-shaped  expansion,  at  the  centre  of 
which  is  a  perforation,  to  be  fitted  over  the  comedo  while 


588    GENERAL  TREATMENT  AND  METHODS 

pressure  is  applied.  The  perforations  should  not  be  of  the 
same  aperture.  Two  such  instruments,  giving  apertures 
of  four  sizes,  will  be  ample  for  all  purposes.  A  slight  rock- 
ing motion  often  aids  in  dislodging  the  little  mass,  or  a 
fine  wire,  such  as  is  carried  in  a  hypodermic  needle,  may 
be  passed  down  into  it  and  thus  loosen  it.  One  should 
be  careful  not  to  bruise  the  tissues.  In  working  near  the 
eye  and  at  the  border  of  the  jaw  the  left  hand  may  be  Used 
to  guard  the  instrument  from  slipping. 

Schamberg's  expressor  terminates  in  a  wide  loop.  It 
is  not  apt  to  become  fouled  during  use,  as  will  sometimes 
occur  with  the  older  instruments. 

The  punch-shaped,  cylindrical  expressors  are  almost 
as  objectionable  as  the  watch-key  which  suggested  their 
construction. 

THE  ACNE  LANCET. 

This  consists  of  a  small,  triangular  blade  furnished  with  a 
shoulder  to  prevent  its  being  introduced  too  deeply.  The 
manner  of  its  use  is  detailed  in  the  article  on  Acne.  It  is 
often  advisable  to  have  the  patient  procure  a  lancet  and 
expressor,  and  instruct  him  in  their  use. 


THE  EPILATING  FORCEPS. 

This  forceps,  until  recently  sharing  with  the  acne  lancet 
and  comedo  expressor  the  first  place  in  point  of  usefulness 
in  the  armamentarium  of  the  dermatologist,  is  now  in 
danger  of  falling  into  comparative  desuetude  through  the 
daily  increasing  use  of  the  o>ray  as  an  epilating  agent. 
It  is,  however,  too  useful  ever  to  be  wholly  laid  aside.  In 
electrolysis  for  hypertrichosis  it  serves  to  discover  the 
success  or  failure  of  the  operation  and  to  lift  out  the  hair. 
It  will  doubtless  still  be  used  in  some  cases  of  tinea  of  the 
scalp  and  beard,  and  of  sycosis.  It  is  of  service  in  alopecia 
areata,  in  clearing  out  the  marginal  hairs,  a  procedure  of 
undoubted  value. 


THE  THERMOCAUTERY  539 

The  forceps  should  have  an  easy  spring  and  perfectly 
smooth,  opposing  surfaces.  Two  shapes  are  useful,  one 
with  broad  ends  terminating  in  straight  borders  with 
which  several  hairs  can  be  seized  at  a  time,  and  another 
with  a  narrow  blade  terminating  in  a  convex  border,  for 
single  hairs. 

Small  mouse-tooth  forceps  are  convenient  for  dislodging 
pediculi  from  the  cilia. 


THE  THERMOCAUTERY. 

The  actual  cautery,  so  called,  which  played  almost  a 
preponderating  part  in  the  surgery  of  the  middle  ages,  is 
little  used  today,  having  been  replaced  first  by  the  Paquelin 
and  later  by  the  galvanocautery. 

It  was  formerly  objected  against  the  Paquelin  instrument 
that  even  the  smallest  points  were  too  bulky  for  some  of  the 
delicate  work  demanded  in  the  destruction  of  the  smallest 
lesions.  This  defect  is  remedied  in  Unna's  microcautery, 
in  which  a  small  wire  is  soldered  to  the  point  of  the  instru- 
ment, thus  permitting  of  effective,  although  sharply  limited 
action.  The  Paquelin  cautery  is  a  most  acceptable  agent 
when  there  is  no  supply  of  electric  energy  at  hand.  With 
it,  as  with  the  galvanocautery,  one  may  regulate  at  will  the 
degree  of  heat  employed. 

The  galvanocautery,  however,  is  more  convenient  for 
office  and  hospital  practice  in  cities  and  towns.  Its  advan- 
tages are,  that  one  may  select  the  size  and  shape  of  point 
desired,  that  it  may  be  managed  with  one  hand  alone,  that 
it  is  less  cumbersome,  thus  admitting  of  greater  precision, 
that  the  heat  need  not  be  turned  on  until  the  instrument  is 
in  contact  with  the  lesion  to  be  destroyed  and  can  at  any 
time  be  turned  off,  and  that  it  is  always  ready  for  use  at  a 
moment's  notice.  It  may  be  operated  by  a  galvanic  battery 
of  low  internal  resistance,  by  storage  cells,  or  by  plugging 
directly  into  the  public  supply,  taking  care  to  interpose  a 
sufficient  resistance. 


590    GENERAL  TREATMENT  AND  METHODS 

Whatever  the  nature  of  the  cautery,  we  should  remember 
the  danger  of  causing  deeper  and  more  extensive  destruc- 
tion than  is  intended.  The  point  should,  therefore,  prob- 
ably never  be  heated  to  more  than  a  cherry  red.  On  the 
other  hand,  if  allowed  to  cool  much  below  that  point,  the 
instrument  will  adhere  to  the  tissues. 

Where  only  a  single,  rapid  application  is  necessary  we 
may  dispense  with  anesthesia;  otherwise  we  may  employ 
cocaine  endermically,  or  freezing  by  ethyl  chloride.  If 
the  latter  agent  be  used,  the  area  to  be  destroyed  should 
first  be  outlined  with  ink  or  an  aniline  pencil. 


SKIN-GRAFTING. 

The  method  devised  by  Thiersch  has  virtually  displaced 
the  older  and  slower  procedures.  It  consists  in  the  im- 
plantation of  long  and  wide  grafts,  which  include  a  layer 
of  corium,  upon  a  granulation-free  surface.  Deformities 
that  would  otherwise  result  from  the  healing  of  the  wound, 
by  granulation  and  consequent  contraction  of  the  scar, 
may  thus  be  prevented,  and  large  surfaces  can  be  rapidly 
healed.  In  Reverdin's  method,  in  which  small  grafts 
limited  to  the  epidermis  are  implanted  upon  a  granulating 
surface,  contraction  of  the  scar  takes  place. 

The  operation  consists  of  the  following  steps:  (1)  Pre- 
liminary preparation  of  the  surface  to  receive  the  grafts; 
(2)  preliminary  preparation  of  the  surface  from  which  the 
grafts  are  to  be  taken;  (3)  final  preparation  of  the  surface 
to  receive  the  grafts;  (4)  removal  of  the  grafts;  (5)  appli- 
cation of  the  grafts;  (6)  subsequent  dressing.  Success 
will  chiefly  depend  upon  strict  asepsis,  especially  in  carry- 
ing out  the  first  two  steps. 

Preliminary  Preparation  of  the  Surface  to  be  Grafted. — In 
the  case  of  a  fresh  operative  wound,  no  especial  prepara- 
tion is  demanded  beyond  the  maintenance  of  asepsis.  A 
granulating  surface  should  be  thoroughly  washed  on  several 
alternate  days,  first  with  soap  and  water,  and  immediately 


SKIN-CRAFTING  591 

after  with  a  solution  of  mercuric  chloride.  After  washing, 
it  is  dressed  with  gauze  soaked  in  Peruvian  balsam.  When 
the  granulations  are  firm,  smooth,  and  red,  the  operation 
may  be  undertaken.  Appropriate  internal  treatment  will 
greatly  aid  in  securing  a  healthy  surface. 

Preliminary  Preparation  of  the  Surface  from  which  the 
Grafts  are  to  be  Taken. — An  arm  or  thigh  may  be  chosen, 
either  of  the  patient  or  of  any  healthy  individual.  The 
anterior  surface  of  the  thigh  is  the  site  of  election.  An 
abundant  hairy  growth  is  no  counterindication,  as  the 
grafts  do  not  include  the  hair  follicles.  The  day  before 
the  operation  the  site  is  shaved,  thoroughly  scrubbed  with 
soap  and  water  and  1  to  1000  mercuric  chloride  solution, 
and  securely  bound  in  sterile  gauze,  which  is  not  to  be  dis- 
turbed until  all  is  ready  for  the  operation,  which  is  to  be 
done  under  strict  aseptic  precautions. 

Final  Preparations  of  the  Surface  to  Receive  the  Grafts. — 
Sclerosed  or  cicatrized  borders  are  cut  away  and  granula- 
tions rapidly  scraped  off  with  a  large,  dull  curette.  Bleed- 
ing is  rapidly  staunched  by  elevation  of  the  part  when 
practicable,  as  in  the  case  of  an  extremity,  and  compression 
with  sterile  sponges.  A  sterile  dressing  is  then  bound  on  or 
maintained  in  place  by  an  assistant. 

Removal  of  the  Grafts. — If  the  operation  be  of  any  extent 
a  general  anesthetic  will  probably  be  required.  The  thigh 
or  other  surface  is  again  washed  with  a  mercuric  chloride 
solution  and  covered  with  gauze  wrung  out  of  the  same, 
over  which  are  secured  sterile  towels  to  be  turned  back  at 
the  last  moment.  After  this,  and  until  the  completion  of 
the  operation,  no  antiseptic  is  used,  but  only  a  sterile 
physiological  salt  solution  (NaCl,  (>  to  JOOO).  Four  basins 
of  this  should  be  at  hand:  one  for  the  hands  (which,  of 
course,  have  been  carefully  prepared),  one  for  gauze 
sponges,  one  for  strips  of  rubber  tissue  (to  be  descrihed 
later),  and  one  for  the  grafts. 

The  surface  being  exposed,  the  operator  takes  a  keen 
razor,  ground  flat  on  one  side.  An  assistant  makes  the 
skin  tense  transversely,  using  both  hands,  The  operator 


592    GENERAL  TREATMENT  AND  METHODS 

makes  longitudinal  tension  with  the  left  hand  at  the  upper 
end  of  the  surface  and  shaves  off  the  graft  downward  with 
a  short,  sawing  motion,  the  blade  being  held  at  a  moderate 
angle  to  the  skin.  The  grafts  may  be  one-half  inch  or  more 
in  width,  as  long  as  one  chooses  or  the  surface  will  allow, 
and  should  include  a  part  of  the  corium.  When  cut  they 
are  dropped  into  the  salt  solution,  where  they  curl  up, 
superficial  surface  outside. 

Application  of  the  Grafts. — All  oozing  having  ceased  from 
the  surface  to  be  grafted,  the  grafts  are  taken  up,  one  end 
straightened  out  with  the  help  of  a  probe  and  laid  on  the 
surface,  and  the  rest  of  the  graft  unrolled.  It  may  then  be 
adjusted  in  place.  Subsequent  grafts  are  carefully  apposed. 
There  is  no  harm  in  a  little  overlapping,  although  the  over- 
lapping border  will  naturally  die  off.  The  whole  surface 
being  covered,  it  is  gently  douched  with  salt  solution. 

Subsequent  Dressing. — Strips  of  rubber  tissue  should 
be  in  readiness.  These  should  be  three-quarters  of  an 
inch  wide  and  long  enough  to  overlap  the  edge  of  the 
wound  at  each  side.  They  should  be  washed  with  soap  and 
water,  soaked  in  sublimate  solution,  and  transferred  to  the 
salt  solution.  These  are  now  carefully  laid  over  the  grafts 
without  disturbing  them,  each  strip  being  overlappped  by 
the  next,  until  all  is  covered.  A  wet  gauze  bandage  applied 
with  moderate  pressure  serves  to  hold  them  in  place.  Over 
this  is  laid  gauze  wrung  out  of  the  salt  solution  and  covered 
with  a  sheet  of  rubber  tissue  to  prevent  evaporation.  Sub- 
limate gauze  cotton  and  a  bandage  complete  the  dressing, 
although  in  case  of  an  extremity  a  splint  should  be  used  to 
secure  immobilization.  The  surface  from  which  the  grafts 
have  been  taken  will  do  well  under  a  simple,  sterile  dressing. 

The  dressings  on  the  grafted  surface  should  be  changed 
every  two  days  for  the  first  eight  days.  The  outer  sheet  of 
rubber  tissue  had  best  be  omitted  after  the  sixth  day,  the 
strips  after  the  tenth,  after  which  a  piece  of  cloth  spread 
with  lanolin  or  vaselin  may  be  applied  for  a  few  days.1 

1  The  technique  here  prescribed  closely  follows  that  given  by 
Theodore  Dunham  in  the  last  edition  of  Buck's  Reference  Handbook. 


HYPER  EM  I A  593 


HOT  AIR. 

Lang  employed  this  agent  in  lupus  erythematosus.  His 
apparatus  is  heated  by  benzine,  and  is  similar  in  principle 
to  the  Paquelin  cautery.  It  is  claimed  that  this  method  is 
free  from  unpleasant  consequences  to  the  patient,  that  it  is 
simple  and  easy  of  application,  even  to  large  areas,  that 
healing  is  rapid,  and  resultant  scars  smooth,  soft,  and 
supple. 

In  Hollaender's  device  for  the  treatment  of  lupus  vul- 
garis  an  air  blast  is  projected  through  a  narrow  metal  tube, 
to  which  heat  is  applied,  the  air  being  raised  to  a  tempera- 
ture of  300°  C.  or  more,  giving  a  cauterant  effect.  The 
patient  is  placed  under  a  general  anesthetic.  Much  care 
and  skill  are  required  in  the  use  of  this  method,  which  is 
capable  of  great  harm.  The  regulation  of  the  temperature 
presents  a  serious  difficulty.  It  is  claimed  that  a  case  has 
been  practically  cured  in  one  sitting. 

Haralamb  has  employed  the  method  in  chancroid. 


PASSIVE  HYPEREMIA.     BIER'S  METHOD. 

Bier's  treatment  of  local  infections  by  the  production  of 
a  passive  hyperemia  was  originally  applied  to  tuberculous 
arthritis,  but  has  recently  been  employed  in  a  variety  of 
conditions.  Bier  recognized  a  therapeutic  effect  in  inflam- 
mation and  its  attendant  edema,  and  sought  to  reproduce 
the  latter  condition  by  obstructing  the  return  circulation. 
In  the  case  of  infection  of  an  extremity,  as,  for  example, 
in  whitlow,  an  elastic  bandage  is  applied  at  a  consider- 
able distance,  namely,  about  the  arm.  Doubtless  the 
method  operates  by  causing  an  increased  phagocytosis, 
the  increased  amount  of  lymph  accumulated  in  the  part 
bringing  an  increased  local  supply  of  opsonins.  Cupping 
glasses  of  various  sizes  are  used  where  a  constricting 
^/bandage  is  not  practicable,  as  about  the  face. 
38 


594 

The  method  has  been  successfully  employed  in  panaris, 
cellulitis,  and  more  recently,  by  Moschkowitz,  in  acne.  A 
small  cupping  glass  operated  by  a  rubber  bulb  is  applied 
for  a  minute  or  two  at  a  time,  such  applications  being 
repeated  at  brief  intervals  during  the  space  of  one  hour. 
Sittings  are  given  daily,  improvement  being  generally 
apparent  in  from  two  to  five  days. 

Stelwagon  has  long  employed  the  cupping  glass  in  acne 
to  facilitate  the  emptying  of  small  pus  foci. 


LIQUID    AIR    AND    SOLIDIFIED    CARBON    DIOXIDE. 

Air  liquefies  at  220°  F.  below  zero  under  a  pressure  of 
thirty-nine  atmospheres.  Several  processes  have,  however, 
been  devised  which,  by  securing  lower  temperatures,  attain 
the  same  result  at  less  than  half  the  pressure,  and  are, 
therefore,  simpler  and  less  costly  of  application.  Thus,  by 
the  apparatus  invented  in  1893  by  Chas.  E.  Tripler,  of 
New  York,  the  product  may  be  manufactured  at  a  cost  of 
two  cents  a  pound. 

Liquid  air,  which  boils  at  about  313°  F.  below  zero, 
is  kept  and  transported  in  specially  constructed  glass  flasks, 
having  a  double  wall  enclosing  a  vacuum.  A  stopper  such 
as  would  prevent  evaporation  would  only  result  in  an 
explosion.  Cotton  is  loosely  fitted  into  the  open  mouth  of 
the  flask,  and  the  fluid  may  thus  be  transported  across  the 
country,  meanwhile  constantly  evaporating.  The  loss, 
while  great,  is  not  so  rapid  as  to  make  transportation 
impracticable. 

If  it  be  at  any  time  necessary  to  filter  the  air,  it  may  be 
done  in  the  usual  way  with  ordinary  filter  paper  and  an 
open  funnel. 

The  method  of  application  is  quite  simple.  A  piece 
of  absorbent  cotton  wrapped  about  the  end  of  a  wooden 
holder  is  plunged  into  the  liquid,  and  applied  to  the 
affected  area  with  moderate  pressure  for  from  two  to  eight 
seconds,  according  to  the  depth  of  destruction  desired. 


LIQUID  AIR  AND  SOLIDIFIED  CARBON  DIOXIDE     595 

The  tissue  is  frozen  and  becomes  snow-white,  of  stony 
hardness,  and  is  depressed  one-eighth  of  an  inch  or  more 
below  the  surrounding  surface.  The  pain  is  not  severe  at 
the  moment  of  application,  but  is  felt  more  within  the 
ensuing  quarter  of  an  hour  or  so,  after  the  tissues  have 
thawed  and  the  blood  finds  its  way  back  into  them.  The 
area  is  then  red,  somewhat  indurated,  and  presents  within 
a  few  hours  a  bleb.  The  later  course  of  the  induced  lesion 
varies  with  the  depth  of  destruction  obtained. 

Solidified  Caxbon  Dioxide. — This  is  employed  for  similar 
purposes  by  W.  A.  Pusey  and  others.  The  liquid  gas  may 
be  had  in  cylinders  fitted  with  a  valve  and  ready  for  use.  • 
The  cylinder  containing  20  pounds  is  convenient  for  the 
use  of  the  physician.  The  valve  being  opened  and  gas 
allowed  to  escape,  its  temperature  is  rapidly  still  further 
lowered  and  condensation  takes  place  in  the  form  of  a 
miniature  snow-storm.  Pusey  advises  that  the  drum  be 
tilted  at  an  angle  of  30  degrees,  the  opening  at  the  lower 
end,  and  the  stream  directed  into  a  chamois-skin  bag, 
when  enough  of  the  material  may  be  collected  and  kneaded 
into  a  little  snowball.  This  is  applied  directly  to  the  part, 
being  held  between  the  bare  fingers  without  damage  to 
the  operator.  This  immunity  is  due  in  part  to  the  thick- 
ness of  the  volar  epidermis  and  in  part  to  the  formation 
of  a  protective  layer  by  volatilization  of  the  gas.  Moderate 
pressure  is  employed.  Five  seconds  will  suffice  for  a 
rubefacient,  ten  for  a  vesicant,  and  fifteen  for  an  escharotie 
effect.  Solid  carbon  dioxide  is  about  half  as  cold  as  liquid 
air. 

These  agents  are  recommended  in  fibrous  nevi,  while 
in  vascular  nevi,  both  plane  and  cavernous,  excellent 
cosmetic  results  are  obtained  with  liquid  air.  They  are 
also  used  successfully  in  other  benign  congenital  growths, 
and  in  a  variety  of  small  neoplasms.  The  method  is  not 
recommended  in  lupus  vulgaris.  Foul  ulcers  may  be 
cleaned  off  by  a  single  application.  Liquid  air  does  well 
in  small  epitheliomata. 


INDEX. 


ACNE,  397 

artificialis,  398 

atrophica,  417 

cachecticorum,  39S 

diagnosis,  399 

etiology,  399 

indurata,  398 

keratosa,  398 

lancet,  588 

lupoid,  417 

necrotica,  417 

pilaris,  417 

rosacea,  413 
treatment,  414 

simplex,  397 

treatment,  400 

urticata,  398 

varioliformis,  417 

x-ravs  for,  410 
Acnitis,  384 

Acrodermatitis  perstans,  135 
Actinomycosis,   Is.") 
Acute  circumscribed  edema.   Hi! 
Addison's  keloid,  218 
Adenoma  sebaceum,  331 
Ainluim,  228 
Aleppo  evil,  360 
Alopt-cia,  432 

areata,  440 

treatment,   I  12.   I  l.">.  ,580 

congenital,  1:52 

pit)'rodes,  433 

premature,  432 

senile,  432 

treatment,  435 
Ammeter,  545 
Anatomical  tubercle,  267 
Anderson's   antipruritic    powder, 
86 


Anesthesia,  artificial,  581 
by  freezing,  581 
by  infiltration,  583 
by  injection,  582 

idiopathic,  362 
Angioma,  239 

cavernosum,  240 

serpiginosum,  246 

simplex,  239 

treatment,  241 

vascularis,  240 
Anidrosis,  383 

Animal  parasitic  affect  ions,    1st; 
Anthrax,  43 
Anticathode,  541 
Antimony,  502 
Antisepsis,  580 
Antiseptic  poultice,  38 
Appendages  of  the  skin,  diseases 

of,  376 
Arsenic,  501 
Asepsis,  580 
Asiatic  pill,  142 
Asphyxia,  local,  176 
Atheroma,  396 
Atrophia  cutis,  227 

pilorum  propria,  428 

unguium,  458 
Atrophies,  225 


B 


HANG'S  lamp,  579 

Barbadoes  leg,  220 

Barber  shops,  precautions  in,  41 

Bassorin  paste,  91 

Hath  pruritus,  371 

Maths,  519 

acid,  520 

alkaline,  520 


598 


INDEX 


Baths,  compound  sulphur,  520 

in  eczema,  95 

mercurial,  520 

soothing  and  emollient,  519 

tar,  520 

Becquerel's  rays,  574 
Bier's  hypersemia,  593 
Biskra  Button,  360 
Blastomycosis,  273 

treatment,  275 
Blue  light,  576 
Bromidrosis,  382 


CALCIUM  chloride,  503 

Callpsitas,  204 

Canities,  419 

Carbolic  acid,  503 

Carbuncle,  40 

Carcinoma  cutis,  338 

Cataphoresis,  536 

Cathode  rays,  540 

Caustics,  515 

Cautery,  589 

Chalk    ointment,     Duckworth's, 

31 

Cheiropompholyx,  50 
Chilblain,  22 
Chloasma,  193 

treatment,  194 
Chromidrosis,  382 
Chromoradiometer,  561 
Cicatrix,  232 

hypertrophied,  230 
Coils,  543 

source  of  energy  for,  545 
Colloid  degeneration,  330 
Comedo,  393 

expressor,  587 

treatment,  394 
Condenser,  543 
Condy's  fluid,  152 
Condyloma,  291 
Corn,  206 

Cornu  cutaneum,  207 
Creeping  eruption,  496 
Cretinism,  sporadic,  223 
Curette,  584 
Cutaneous  punch,  587 
Cysticercus      cellulosjr      cutis, 
'496 


DARIEK'S  disease,  335 
Defluvium  capillorum,  436 
Delhi  boil,  360 
Dermatalgia,  361 
Dermatitis  calorica,  184 
exfoliativa,  acute,  152 
chronic,  153 
epidemica,  156 
infantum,  155 
fact  it  ia,  180 
gangrsnosa,  175 
diabetic,  176 
infantum,  176 
symmetrical,  176 
treatment,  177 
herpetiformis,  66 
treatment,  67 
medicamentosa,  178 

treatment,  179 
papillaris  capillitii,  233 
repens,  135 
traumatica,  181 
venenata,  181 

treatment,  182 
£-ray,  186 

manner  of  production,   569 
necessity  for,  568 
treatment,  186 
Dermo  lamp,  579 
Dysidrosis,  50 


E 

ECHINOCOCCUS  cyst,  496 
Ecthyma,  48 
Eczema,  71 

diagnosis,  77 

erythematous,  73 

etiology,  75 

fissum,  75 

infantile,  75,  121 

inter  trigo,  109 

of  anus,  109 

of  beard,  106 

of  breast,  107 

of  ears,  102 

of  face,  98 

of  feet,  113 

of  flexor  surfaces,  109 

of  genitals  112 


INDEX 


599 


Eczema  of  hands,  113 
of  joints,  109 
of  legs,  117 
of  lids,  105 
of  lips,  103 
of  nails,  116 
of  nares,  102 
of  nipple,  107 
of  perineum,  109 
of  scalp,  95 
of  umbilicus,  108 
papular,  73 
prognosis,  123 
pustular,  74 
rubrum,  74 
sclerosum,  75 
seborrhoicum,  131 
treatment,  133 
squamosum,  75 
treatment,  internal,  78 
local,  82 

by  baths,  95 
by  electricity,  122 
by  glycerin  jelly,  92 
by  liniments,  87 
by  lotions,  83 
by  massage,  95 
by  mechanical  support ,  95 
by  ointments,  87 
by  paints,  94 
by  pastes,  90,  91 
by  phototherapy,  122 
by  plasters,  93 
by  powders,  86 
by  x-rays,  122 
universal,  119 
verrucosum,  75 
vesicular,  74 
Edema,  circumscribed,  acute,  164 

of  the  newborn,  215 
Electric  valve,  546 
Electrical  osmosis,  536 
Electrolysis,  535 

for  acne  rosacea,  536 
hypertrichosis,  421 
Klcphantiasis,  220 

treatment,  222 
Epidermolysis,  71 
Epilating  forceps,  588 
Kpilation  by  .r-ruys,   126,  473 
Kpithelioma,  339' 
deep,  340 
diagnosis,  341 


Kpithelioma,      multiple     benign 

cyst  ic,  332 
papillary,  341 
superficial,  339 
treatment,  343 

by  cataphoresis,  350,  538 

by  caustics,  344 

1>\  cautery,  348 

by  electrolysis,  348 

by  phototherapy,  357 

by  radium,  357 

by  static  electricity,  357 

surgical,  343 

by  trypsin,  349 

by  x-rays,  350 

choice  of  cases  for,  350 
technique  in,  352 
Equinia,  44 
Erysipelas,  29 
Erysipeloid,  33 

Erythema  elevatum  diutinum,  28 
idiopathic,  17 
induratum,  272 
infantile,  20 
intertrigo,   17 
keratodes,  200 
multiforme,  24 
nodosum,   26 
pernio,  22 
scarlatiniforme,  20 
simplex,  17 
symptomatic,  19 
.r-ray,  186 

Erythemata,  exudative,  24 
Krythrasma,  482 
Krythrodermia,  172 
Krvthrodermie  pityriasi<|i:r,    1">''> 


FAKADISM,  529 
l-avus,  460 

of  nail,  458 

treatment,  462 
Feigned  eruptions.  I^u 
I  il.roma,  233 

molluscuin.  '_':>  I 

multiple.  234 

pendulum,  234 
Kilaria  incdinrtisk    I'.i.'i 
l-'inscn  lamp.  ">77 
I'insrii-Kryn  lamp.  .">7.s 


600 


INDEX 


Fish-skin  disease,  212 
Fluoroscope,  538,  557 
Focus  tube,  541 
Folliclis,  384 

Folliculitis    capillitii    desquama- 
tiva,  431 

decalvans,  446 
Forceps,  epilating,  588 
Fragilitas  crinium,  428 
Frambcesia,  359 

syphilitica,  295 
Freckles,  192 
Freezing  for  anesthesia,  581 

therapeutic,  594 
Frostbite,  184 
Furuncle,  35 
Furunculus  orientalis,  360 


GALVANISM,  527 
Galvanocautery,  589 
Gangrene  of  skin,  diabetic,  176 

in  children,  176 

multiple,  175 

symmetrical  176 

treatment,  177 
Gelanthum,  92 

General  treatment  and  methods, 
501 

internal,  501 

local,  505 
Glanders,  44 
Glycerin  jelly,  92 
Glycogelatins,  513 
Granulosis  rubra  nasi,  387 
Gray  hair,  419 
Green  soap,  tincture  of,  437 
Guinea-worm,  495 
Gumma,  scrofulous,  269 
syphilitic,  296 


HAIR,  atrophy  of,  428 

beaded,  430 

follicles,  affections  of,  419 

gray,  419 

superfluous,  419 
treatment,  421 
Harlequin  fetus,  213 


Hemorrhages,  188 
Hereditary  syphilis,  309 
Herpes  facialis,  52 

iris,  25 

neuralgic,  repeating,  60 

progenitalis,  53 

zoster,  55 

Hidradenitis  suppurativa,  383 
Hidrocystoma,  386 
High-frequency  current,  27 
Hirsuties,  419 
Hives,  157 

Hollaender's  method,  593 
Holtz  influence  machine,  530 
Holzknecht  unit,  22 
Horn,  207 
Hot  air,  593 
Hydroa  a-stivale,  70 

vacciniforme,  70 
Hyperemia,  Bier's,  593 
Hyperidrosis,  376 

treatment,  377 

Hyperkeratosis  congenita,  213 
Hypertrichosis,  419 
Hypertrophied  scar,  230 


ICHTHYOL,  502 
Ichthyosis,  212 

congenital  213 

hystrix,  213 

treatment,  214 
Ihle's  paste,  91 
Impetigo  contagiosa,  45 
bullpus,  46 
circulate,  46 

herpetiformis,  65 
Incandescent  lamp,  579 
Inductance,  544 
Induction  coil,  543 
Infiltration  anesthesia,  583 
Influence  machine,  530 
Ingrowing  toe-nail,  457 
Insect  bites,  497 
Internal  treatment,  general,  "><)! 
Interrupter,  autonome,  548 

Caldwell-Simon,  550 

Contremoulin,  547 

electrolytic,  548 

Mackenzie  Davidson.  ")47 

mercury  dip,  547 


IXDEX 


001 


Interrupter,  mercury  jet,  547 

synchronized,  547 

turbine,  547 

vibrating,  546 
Iodides,  504 

Iron-electrode  lamps,  579,  5  so 
Itch,  486 

diagnosis,  488 

treatment,  489 
Ivy  poison,  182 


JACKSON'S  tube,  541 


KELOID,  230 

Kerato-angipma,  203 

Keratodermia  erythematosa  sy in- 
met  rica,  200 

Keratosis  follicularis,  335 

contagiosa,  336 
palmaris  et  plantaris,  199 
pilaris,  198    • 
senilis,  201 

Kerion,  467 

Kraurosis  vulva1,  227 

Krornayer's  punch,  411 

Kummerf eld's  lotion,  415 


I. AMI-,  Jiang's,  579 
Dt-rmo,  579 
Kinsen,  577 
Finsen-Reyn,  578 
incandescent.  579 
iron-electrode.  579,  580 
London  Hospital,  578 
Lort-et  and  (Icnoud.  57  - 
mercury-vapor,  579 
Piffard's,  57!  I 
I'viol,  579 

l.a-sar's  paste,  19 

Lentigo,  192 

Lepothrix,  382,  430 

Leprosy,  320 
anesthetic,  322 


Leprosy,  mixed,  324 
nodular,  321 
treatment,  325 
Leucoderma,  225 
Leucokeratosis  buccalis.  :;:;_' 
Leucopathia  unguium,  459 
Leucoplakia,  332 
Lice,  491 
of  body,  493 

treatment,  494 
of  head,  491 

treatment,  492 
of  pubes,  494 

treatment,  494 
Lichen  pilaris,  171 
planus,  165 
etiology,  167 
treatment,  167 
scrofulosorum,  271 
spinulosus,  171 
tropicus,  384 
urticatus,  158 
variegatus,  156 
Lichenoid  eruption,  156 
Liniments,  516 
calamine,  Crocker's,  51  (i 
in  eczema,  87 
Linimentum  exsiccans,  91 
Lipoma,  236 
Liquid  air,  594 
Liquor  picis  alkalinus,  85 
Local  applications,  505 
London  Hospital  lamp,  578 
Jx)rtet  and  Genoud  lamp.  57s 
Lotions,  506 
calamine-zinc,  162 
in  eczema,  83 
Startin's,  84 
zinc-oxide  compound.  sj 
Lupus  erythemat<»n>.  ~27~> 
circumscribed,  276 
disseminate,  277 
nodular,  277 
telangiectatic,  277 
treatment,  278 

.<•-!•:»  ys  in,  285 
vulgaris,  251 
diagnosis,  J5:-> 
crvthcinatodcs,  252 
liv|M>rtropliicus,  252 
papillomatosus,  252 
serpiginosus,  252 
tivat  incut.  1>5<1 


(M)2 


INDEX 


Lupus   vulgaris,  treatment,  hot 

air  in,  293 

phototherapy  in,  262 
scarification  in,  586 
x-rays  in,  263 

Lvmphangioma  circumscriptum, 
"236 

M 

MADURA  foot,  484 
Malignant  pustule,  43 
Massage  in  eczema,  95 
Mentagra,  448 
Mercury,  504 

vapor  lamp,  579 
Microcautery,  589 
Miliaria,  384 

treatment,  385 
Milium,  395 

Milliammeter  for  secondary  cir- 
cuit, 550 

Mineral  waters,  504 
Mistura    ferri    acida,    Start in's, 

27,  79 

Moist  papule,  291 
Mole,  211 
Molluscum  contagiosum,  337 

epitheliale,  337 

sebaceum,  337 
Monilethrix,  430 

Morbus  maculosus  Werlhofii,  188 
Morphea,  218 

treatment,  219 
Motor  generator,  546 
Multiple  benign  cystic  epitheli- 
oma,  332 

gangrene  of  skin,  175 
Muscidse,  498 
Mycetpma,  484 
Mycosis  fungoides,  314 

treatment,  316 
Myiasis,  498 
Myoma,  235 
Myxedema,  223 


N 

N.EVUS  araneus,  245 
pigmentosus,  211 
vasculosus,  243 

Nails,  atrophy  of,  458 


Nails,  diseases  of,  454 
favus  of,  458 
ringworm  of,  458 
white  spots  of,  459 

Nettle-rash,  157 

Neuroma,  235 

Neuroses,  361 

New  growths,  230 


(EDEMA.    See  Edema. 

neonatorum,  215 
(Estrus,  498 
Oils,  516 
Ointments,  507 

chalk,  Duckworth's,  31 

compound  starch,  101 

diachylon,  89 

in  eczema,  87 

Jamieson's,  88 

Piffard's,  511 

preparation  of,  508 

Wilkinson's,  113 
Onychauxis,  454 
Onychia,  456 
( )nychomycosis,  *458 

treatment,  476 
Opsonic  index,  521 

method,  520 
Osmoregulator,  552 


FACET'S  disease  of  nipple,  357 

treatment,  358 
Paints,  94,  517 

Pick's,  518 

Provan's,  518 

Papillary  growths  on  sole,  210 
Paquelin  cautery,  589 
Parakeratosis  variegata,  156 
Parapsoriasis,  157 
Parasitic  diseases,  vegetable,  4C>0 
Paronychia,  256 
Passive  hyperemia,  593 
Pastes,  511 

bassorin,  91 

Ihle's,  91 

Lassar's,  90 

Rosenthal's,  104 


INDEX 


603 


Pediculosis,  491 

capillitii,  491 
treatment,  492 

corporis,  493 
treatment,  494 

pubis,  494 

treatment,  494 
Pellagra,  33 
Pemphigus,  60 

acute,  61 

chronic,  61 

foliaceus,  61 

vegetans,  62 

vulgaris,  61 

treatment,  64 
Perforating  ulcer,  227 
Pernio,  22 
Phosphorus,  503 
Phototherapy,  576 

action  on  tissues,  580 

apparatus  for,  577 

for  alopecia  areata,  445,  580 

for  eczema,  122 

for  epithelioma,  357 

for  erysipelas,  32 

for  furunculus  orientalis,  360 

for  lupus  erythematosus,  284 
vulgaris,  256 

for  mrvus  vasculosus,  245 

for  psoriasis,  148 

for  smallpox,  577 

for  sycosis,  453 

for  x-ray  ulceration,  187 

negative,  577 

positive,  577 

technique,  579 
Piebald  skin,  225 
Piedra,  431 
Piffard's  comedo  expressor,  57 

lamp,  579 

tube,  555 

Pigmentation  after  .r-rays,  60 
Pinta  disease,  484 
Pityriasis  marulata  et  circiimta, 
*  150 

rosea,  150 

rubra,  153 
pilaris,  172 

treatment,  174 
Plaster  mulls,  514 
Plasters,  93,  514 

salicylated  soap,  93 
Podelcoma,  484 


Poison,  dogwood,  182 

elder,  182 

ivy,  182 

oak,  182 

sumach,  182 
Pompholyx,  50 
Porokeratosis,  203 
Port-wine  mark,  243 
Poultices,  516 
Powder  stains,  196 
Powders,  505 

Anderson's,  86 
Prickly  heat,  384 
Protection  from  x-rays,  551,  ">.r>(i 
Prurigo,  136 
Pruritus,  362 

ani,  372 

bath,  364,  371 

diagnosis,  365 

hiemalis,  303,  371 

localis,  363 

scroti,  371 

treatment,  366 

univcrsalis,  363 

vulva-,  373 

Psoriasiform  dermatoses,  156 
Psoriasis,  137 

diagnosis,  140 

etiology,  140 

prognosis,  140 

syphilitica,  292 

treatment,  140 

phototherapy  in,  1  is 
x-rays  in,  148 
Punch,  cutaneous,  587 
Purpura,  188 

h:i  inorrhagica,  188 

rheumatica,  189 

simplex,  188 

treatment,   1!H) 


QriMNi:.  .in:? 
Quinquaud'a  disease,  1 17 


RADIO-ACTIVITY,  .">7.~> 
Radiochromometer,    BenoM '-. 
558 


604 


INDEX 


Radiometer,  Freund's,  562 

Sabouraud  and  Noir6's,  562 
Radium,  574 

in  psoriasis,  148 
Raynaud's  disease,  176 
Resonator,  502 
Rheostat,  546 
Rhinoscleroma,  249 
Rhus  poisoning,  182 
Ringworm,  465 
black  dot,  467 
of  beard,  477 
diagnosis,  478 
treatment,  479 
of  body,  474 

treatment,  476 
of  scalp,  466 
treatment,  468 
x-rays  for,  473 
Rodent  ulcer,  340 
Rontgen  ulcer,  570 
Roseola  infantilis,  20 


SALICYLIC  acid,  503 

soap  plaster,  37 
Salve  pencil,  512 

stick,  116 

Salves.    See  Ointments. 
Sapo  olivse,  prseparata,  86 
Sarcoma  cutis,  317 

idiopathic  multiple  pigment  ed, 
318 

melanotic,  317 

Hon-pigmented,  317 

treatment,  319 

by  cataphoresis,  538 
by  mixed  toxins,  526 
by  trypsin,  349 
by  x-rays,  320 
Scabies,  486 

diagnosis,  488 

treatment,  489 
Scar,  232 

hypertrophied,  230 
Scarifier,  585 

Schamberg's  expressor,  588 
Schleich's  anesthesia,  583 
Scirrhus,  338 

Sclerema  neonatorum,  215 
Scleroderma,  216 


Scleroderma,  circumscribed,  218 

treatment,  218 
Scrofulides,  269 

treatment,  270 
Scrofuloderma,  269 
Scurvy, land,  188 
Sebaceous  glands,  diseases  of,  388 
Seborrhea,  388 

general,  389 

of  face,  389 

of  scalp,  388 

of  umbilicus,  389 

treatment,  390 
Seborrheic  eczema,  131 
Shelling  methods,  in  acne,  407 
Shields  for  x-rays,  554 
Skin  grafting,  590 
Soaps,  517 
Solenoid,  532 
Spark  gaps,  544 
Spider  nevus,  245 
Spintermeter,  545 
Spiritus  saponatus  kalinus,  86 
Startin's  lotion,  84 
Static  electricity,  529 

machine,  542 
Sudamen,  386 
Sulphur,  502 
Suprarenal  extract,  504 
Sweat  glands,  diseases  of,  376 
Sycosis,  coccogenic,  448 

non-parasitic,  448 

treatment,  450 

Symmetrical  gangrene  of  skin,  176 
Syphilide,  annular  291 

bullous,  296 

erythematous,  289 

exanthematous,  289 

furuncular,  311 

gummatous,  296 

macular,  289 

palmar  and  planter,  292 

papular,  290 

pigmentary,  290 

pustular,  293 

squamous,  292 

tubercular,  295 
Syphilis,  287 

cutanea  bullosa,  296 
gummatosa,  296 
maculosa,  289 
papillomatosa,  296 
papulosa,  290 


INDEX 


605 


Syphilis,  cutanea  pustulosa,  293 
squamosa,  292 
tuberculosa,  295 
vegetans,  292 
hereditary,  309 

treatment,  312 
treatment,  297 

by     hypodermic     injection, 

'300 

by  inunction,  299 
local,  309 

Syphilitic  roseola,  289 
Syphiloderma  bullosum,  296 
erythematosum,  289 
gummatosum,  296 
palmaris  et  plantaris,  292 
papulosquamosum,  292 
papulosum,  290 
pustulosum,  293 
tuberculosum,  295 
Syphilodermata,  287 


TAR,  503 
Target,  541 
Tattoo  marks,  196 
Telangiectasis,  240 

from  z-rays,  570 
Thermocautery,  589 
Thiersch  grafts,  590 
Thyroid  gland,  503 
Tincture  of  coal-tar,  compound, 

86 

Tinea  barbse,  477 
treatment,  479 

circinata,  474 
treatment,  476 

imbricata,  480 

tonsurans,  466 
treatment,  468 

versicolor,  481 

treatment,  482 
Toepler-Holtz  influence  machine, 

.->:;<) 

Toxicodendrol,  182 
Toxins     of     erysipelas     aiul     H. 
prodigiosus,  52(> 

mixed,  Coley's.  ."iiM 
Traumaticine,  145 
Trichophyton,  4<>f> 
Trichorrhexis  nodosa,  429 
Trikresol,  443 
Trypsin  in  malignancy,  349 


Tube  stand,  553 
Tuberculosis  dissemiuata,  268 

exanthematic  miliary,  268 

of  the  skin,  250 

ulcerosa,  268 

verrucosa,  267 
Tubes.     See  X-rays. 
Turpentine,  503 


ULCUS  perforans,  227 

varicosus,  126 

Ulerythema  sycosiforme,  447 
Ultra-violet  rays,  576 
Uncinarial  dermatitis,  498  . 
Unguenta.    See  Ointments. 
Unguentum  diachylon,  89 

vaselini  plumbicum,  89 
I'liguis  incarnatus,  456 
Urticaria,  157 

etiology,  159 

factitia,  158 

pigmentosa,  163 

treatment,  160 
Uviol  lamp,  579 


VACCINES,  bacterial,  524 
Varicose  ulcer,  126 
Varnishes,  517 

Vegetable  parasitic  diseases,  460 
Verruca,  207 

acuminata,  210 

filiformis,  208 

necrogenica,  267 

plana  juvenilis,  208 

senilis,    208 

treatment,  209 
Violet  light,  576 
Vitiligo,  225 

treatment,  226 
Vitiliijni.lea.  23(1 
Yleminekx's  solution,  406 

Voltmeter.    .")).") 

w 

WAHT,  207 

acuminate.  'Jin 
filiform,  208 
juvenile,  208 


006 


INDEX 


Wart,  senile,  208 
treatment,  209 
Wen,  396 

Wilkinson's  ointment,  113 
Winter  itch,  371 


XANTHELASMA,  236 
Xanthelasmoidea,  163 
Xanthoma,  236 

diabeticorum,  237 

planum,  236 

tuberculatum,  237 

treatment,  238 

Xeroderma  pigmentosum,  247 
A'-rays,  angle  of  impact,  563 

bactericidal  effect  of,  573 

choice  of,  556 

dermatitis  from,  186 
latency,  of,  572 
necessity  for,  568 

discovery  of,  538 

dosage,  556,  564 

for  acne,  410 

rosacea,  417 
varioliformis,  418 

for  alopecia  areata,  444 

for  blastomycosis,  275 

for  eczema,  122 

for  epithelioma,  350 

for  favus,  460 

for  furunculus  orientalis,  360 

for  hyperidrosis,  380 

for  hypertrichosis,  426 

for  ichthyosis,  215 

for  keloid,  232 

for  leprosy,  329 

for  leucoderma,  226 

for  leucoplakia,  335 

for  lichen  planus,  170 

for  lupus  erythematosus,  285 
vulgar  is,  263 

for  multiple  benign  cystic  epi- 
thelioma, 332 

for  mycosis  fungoides,  316 

for  mevus  pigmentosus,  212 
vasculosus,  245 

for  pityriasis  rubra  pilaris,  175 

for  prurigo,  137 

for  psoriasis,  148 

for  ringworm,  473,  480 


A'-rays  for  sarcoma,  320 
for  scrofuloderma,  270 
for  sycosis,  452 
for  urticaria  pigmentosa,  164 
for  verruca,  210 
for  xanthoma,  239 
for  xeroderma,  249 
Hplzknecht  unit,  562 
idiosyncrasy  toward,  572 
mode  of  action,  186 
'  'normal"  exposure,  566 
penetration  of,  557 
physics  of,  538 
pigmentation  from,  570 
properties  of,  540 
protection  of  operator,  556 

of  patient,  554 
quality  of,  557 
quantity  of,  558,  561 
shields,  554 
sittings,  duration  of,  560 

intervals  between,  560 
telangiectasis  from,  570 
tube,  Crookes',  539 

distance  of,  559 

focus,  591 

hard,  551 

Jackson's,  541 

Midler's,  552 

Piffard's,  555 

regulation  of,  552 

resistance  of,  551 

Sayen's,  553 

self-regulating,  552 

soft,  551 

stand,  553 

Thomson's,  553 

vacuum  in,  551 
ulceration  from,  186,  570 
velocity  of,  541 


YAWS,  359 


ZINC-CALAMINE  lotion,  22 

Zinc  sulphide  lotion  compound, 

23 

Zona,  55 
Zoster,  55 


Date  Due 


CAT.    NO     ?3    233 


PRINTED    IN    U.S.A. 


WR650 
H258h 
1907 
Hardaway,  William  A 

Handbook  of  cutaneous  therapeutics 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


